The findings of the on-site investigation, conducted 06/14/22 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.

Based on interview and record review, during a site visit conducted on 06/14/23, it was confirmed that the facility failed to promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (# 2). Findings include, but not limited to:

During an interview on 06/13/23  Staff 1 (Executive Director) stated, he completed a "grievance form" form when the money was reported stolen. He stated this was not what the facility typically  used to investigate abuse or neglect. The facility reported that matter to the police, but did not report to APS. He felt it was "too murky" to consider it as abuse or neglect and warrant an investigation because the resident had left the facility with their purse for outside appointments. Staff 1 explained they have a process in Service Minder (care-planning platform) called risk management for abuse and neglect investigations. He stated they interviewed staff, family, and Resident 2 but did not document the interviews.

No documentation of an investigation was provided by the facility other than a grievance form dated 02/15/23. The bottom of the form had instructions to "Attach investigative process, copies of in services held and attendance sheet" though no attachments were included.

The findings were reviewed with and acknowledged by Staff 1 on 06/14/23.

The facility failed to promptly investigate a report of stolen property of abuse and suspected abuse, and take measures necessary to protect residents and prevent the reoccurrence.

Verbal plan of correction: A copy of the ODHS abuse investigation and reporting guide was provided by email on 06/15/23. Staff 1 and Staff 2 (Director of Nursing) to review and will investigate and document investigations for any claims of financial abuse and exploitation in addition to their normal risk management form or other forms of alleged abuse and neglect.

Based on observation, interview and record review, during a site visit conducted on 06/14/23, it was confirmed the facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents for 1 of 1 sampled resident (#3). Findings include, but not limited to:

During an observation and interview, Resident 3 engaged their call light at 12:38 pm. A caregiver responded to the call light at 1:00 pm (22 minutes) and assisted Resident 3 to the bathroom.

During the interview on 06/14/23, Resident 3 stated s/he regularly has to wait a very long time for help from a caregiver, sometimes up to 45 minutes. Resident 3 thinks his/her bladder infections are caused by having to hold urine for so long while waiting to get assistance. S/he further stated, it is really stressful when s/he has to wait, and weekends are the worst time for staffing related to the the facility being short-staffed.  S/he reported sometimes they have to call the front desk to get someone to help.

During interviews on 06/14/23, Staff 4 (caregiver), Staff 5 (LPN) and Staff 6 (Medication Technician) stated call lights should be responded to within 15 minutes. Staff 4, Staff 5 and Staff 6 all stated "there is not enough staff to meet resident needs sometimes", especially if there are multiple residents using their call lights at the same time.

Resident 3's call light logs for 05/15/23 through 06/14/23 revealed 36 occasions when Resident 3 waited longer than 15 minutes for a response to his/her call light. Ten of those occasions were longer than 45 minutes.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director) on 06/14/23.

The facility failed to have sufficient staff to meet the scheduled and unscheduled needs of the residents.

Verbal plan of correction: Staff 1 to review call light logs weekly and discuss in the health services meeting. S/he will review the ABST process with the home office to develop a consistent staffing process. The facility was currently undergoing a transition with the staffing coordinator who stepped down. The facility was actively recruiting for two staffing coordinators and direct care staff.

Based on interview and record review, during a site visit conducted on 06/14/23, it was confirmed that the facility failed to implement an Acuity-Based Staffing Tool (ABST). Findings include, but not limited to:

During interviews on 06/14/23, Staff 1 (Executive Director), Staff 2 (Director of Nursing), and Staff 3 (Quality Care Coordinator) stated their care-planning platform, Service-Minder tool had their ABST built-in. The document used was called "Summary by Provider". They entered the residents data into the tool to generate how many hours of care was needed per day to figure out the facilities staffing plan. The process was completed once a month. If a resident had a service plan change, it would be reflected immediately in the summary by the provider, but not on the ABST. If residents had changes of conditions that required service plans updates and increased level of care, they stated they would discuss that in the morning meeting, and Staff 3 would update the schedule for the week.

A review of the May 2023 ABST documents provided lacked residents' names. The Compliance Specialist requested  the ABST for June 2023 or any current ABST documentation. Staff 1 was unable to provide documentation of the June 2023 ABST, as it had not yet been completed, and would not be until July 2023. The facility was unable to provide documentation of their ABST review process for new move-ins, updates with service planning or changes of conditions.

There was no documented evidence the facility changed their staffing plan to reflect resident care needs.

The finding were reviewed with and acknowledged by Staff 1 on 06/14/23.

The facility failed to fully implement an ABST.

Verbal plan of correction: Staff 1 will contact the home office for regarding the facilities ABST and staffing. Until that time, they will review their "summary by provider" report and staffing schedule in daily health services meeting and document the review for new move-ins, changes in service planning/care needs, and changes of conditions, and implications for staffing needs.