Print Inspection: 0PBO

Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to post the name of the designated person in charge by shift or whenever the Administrator is out of the facility. Findings include, but are not limited to:

On 06/11/24 at 4:43 pm and on 06/12/24 at 9:04 am, the Compliance Specialist entered the facility and did not observe a licensed administrator to be onsite.

In separate interviews on 06/11/24, Staff 1 (RCC), Staff 5 (CG), Staff 6 (MT), Staff 7 (RCC), Staff 8 (CG), and Staff 9 (CG) stated the following:

* At 4:45pm: "There is no administrator for the [memory care]."

* The previous administrator stepped down two weeks ago.

* If [s/he] doesn't know who's the manager on duty, s/he will go to the med tech.

* At 5:00 pm: "[Staff 4] is available via phone [and] not scheduled to be onsite this week."

* At 5:30pm: "The Administrator is [Staff 3]."

* There was no information provided on who was to fill in when Staff 2 (former MCC Administrator stepped down.

*At 5:45 pm, since Staff 2 stepped down, s/he can't say there's been a licensed administrator onsite for 40 hours.

In an interview on 06/11/24 at 6:55 pm, Staff 4 (Regional Director of Operations) stated the following:

* Staff 3 (Administrator) notified the Department via email on 05/21/24 that s/he would be temporarily absent starting on 05/22/24.

* Staff 3 went out on leave on 05/22/24.

* Staff 3 had an exception [to be administrator] for ALF and MCC.

* S/He was in charge when Staff 3 went out on leave.

* Staff 2 stepped down on 05/28/24.

* S/He is onsite every week.

* Last week, s/he was onsite for a full three days and partially on a fourth day and completed two evaluations for assisted living and one evalution for memory care.

When asked what actions were taken with facility staff when Staff 3 stepped down, Staff 4 was unable to provide an answer.

On 06/11/24 at 7:35 pm, there were no waivers or exceptions granted or provided that allowed the facility to operate without an administrator.

On 06/11/24 at approximately 4:45 pm, it was observed in both the ALF and MCC, the facility's required Designated Person in Charge signage stated "Health Care Coordinator" but lacked the name of the staff member in charge. By 7:35 pm, the signage was updated with a name.

On 06/12/24 at 9:05 am, it was observed there was no administrator onsite and the assisted living facility's required Designated Person in Charge signage said "Health Care Coordinator" but lacked the name of the staff member in charge. At 9:16 am, there was no administrator onsite and the MCC facility's required Designated Person in Charge signage was blank.

In separate interviews on 06/12/24, Staff 10 (MT), Staff 11 (CG), Staff 12 (CG) and Staff 13 (LPN) stated the following:

* S/He identified the RCCs or nurses as the person in charge.

* At 9:16 am: "[Staff 2 (former MCC Admin)] stepped down in the end of May."

* S/He stated the RCC was in charge when Staff 2 stepped down.

* Staff 4 was in the MCC last week when s/he asked about the service plan binder.

* S/He did not have Staff 4's contact information.

* The previous memory administrator, before Staff 2, left that role in February 2024.

* There was no communication to care staff who was filling in as interim Administrator.

* Staff 4 spent his/her time last week in Staff 3's office.

* Before [Staff 3] went out on leave, s/he sent an email to facility management who would be in charge, but nothing was communicated to the caregivers.

* Last week [Staff 4] was onsite three to four days for approximately 10 hour days.   

In an interview on 06/12/24 at 10:38 am, Witness 1 and Witness 2 stated s/he has not seen any manager in the MCC during their visits.

In an interview on 06/12/24 at 11:13 am, Witness 3 and Witness 4 (family members) stated they are in the facility once-to-twice per week. If s/he had concerns, they would go the front desk for help. The MT is usually the staff member in charge unless the "front office door is open, then [s/he would] go to them. But they had a change and don't know who is in charge now."

On 06/12/24 at 12:00 pm, Staff 4 was observed to be onsite in the MCC. CS requested Staff 4 provide a written schedule of his/her time onsite.

In an email, dated 06/12/24, Staff 4 indicated s/he worked "remote" during the week "05/22- 05/28".

In an interview on 06/13/24 at 9:00 am, Witness 5 (ODHS OPA) stated the following:

* S/He was notified on or about 05/21/24 via email that Staff 3 will be out and Staff 4 would take over.

* S/He was with the understanding that Staff 4 would be onsite 40 hours.

* S/He did not have the paperwork required of and for times when a new administrator is stepping into the administrator role for Staff 2.

On 06/13/24 at 9:35 am, via telephone, these findings were reviewed with Staff 4. Staff 4 stated his/her team was onsite and s/he was available by phone.

Verbal Plan of Correction:

The Interim Administrator will be onsite in the community 40-hours until the Executive Director returns.

Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to provide a full-time administrator to be onsite 40 hours per week; and the facility failed to post the name of the designated person in charge by shift or whenever the Administrator is out of the facility. Findings include, but are not limited to:

On 06/11/24 at 4:43 pm and on 06/12/24 at 9:04 am, the Compliance Specialist entered the facility and did not observe a licensed administrator to be onsite.

In separate interviews on 06/11/24, Staff 1 (RCC), Staff 5 (CG), Staff 6 (MT), Staff 7 (RCC), Staff 8 (CG), and Staff 9 (CG) stated the following:

* At 4:45pm: "There is no administrator for the [memory care]."

* The previous administrator stepped down two weeks ago.

* If [s/he] doesn't know who's the manager on duty, s/he will go to the med tech.

* At 5:00 pm: "[Staff 4] is available via phone [and] not scheduled to be onsite this week."

* At 5:30pm: "The Administrator is [Staff 3]."

* There was no information provided on who was to fill in when Staff 2 (former MCC Administrator stepped down.

*At 5:45 pm, since Staff 2 stepped down, s/he can't say there's been a licensed administrator onsite for 40 hours.

In an interview on 06/11/24 at 6:55 pm, Staff 4 (Regional Director of Operations) stated the following:

* Staff 3 (Administrator) notified the Department via email on 05/21/24 that s/he would be temporarily absent starting on 05/22/24.

* Staff 3 went out on leave on 05/22/24.

* Staff 3 had an exception [to be administrator] for ALF and MCC.

* S/He was in charge when Staff 3 went out on leave.

* Staff 2 stepped down on 05/28/24.

* S/He is onsite every week.

* Last week, s/he was onsite for a full three days and partially on a fourth day and completed two evaluations for assisted living and one evalution for memory care.

When asked what actions were taken with facility staff when Staff 3 stepped down, Staff 4 was unable to provide an answer.

On 06/11/24 at 7:35 pm, there were no waivers or exceptions granted or provided that allowed the facility to operate without an administrator.

On 06/11/24 at approximately 4:45 pm, it was observed in both the ALF and MCC, the facility's required Designated Person in Charge signage stated "Health Care Coordinator" but lacked the name of the staff member in charge. By 7:35 pm, the signage was updated with a name.

On 06/12/24 at 9:05 am, it was observed there was no administrator onsite and the assisted living facility's required Designated Person in Charge signage said "Health Care Coordinator" but lacked the name of the staff member in charge. At 9:16 am, there was no administrator onsite and the MCC facility's required Designated Person in Charge signage was blank.

In separate interviews on 06/12/24, Staff 10 (MT), Staff 11 (CG), Staff 12 (CG) and Staff 13 (LPN) stated the following:

* S/He identified the RCCs or nurses as the person in charge.

* At 9:16 am: "[Staff 2 (former MCC Admin)] stepped down in the end of May."

* S/He stated the RCC was in charge when Staff 2 stepped down.

* Staff 4 was in the MCC last week when s/he asked about the service plan binder.

* S/He did not have Staff 4's contact information.

* The previous memory administrator, before Staff 2, left that role in February 2024.

* There was no communication to care staff who was filling in as interim Administrator.

* Staff 4 spent his/her time last week in Staff 3's office.

* Before [Staff 3] went out on leave, s/he sent an email to facility management who would be in charge, but nothing was communicated to the caregivers.

* Last week [Staff 4] was onsite three to four days for approximately 10 hour days.   

In an interview on 06/12/24 at 10:38 am, Witness 1 and Witness 2 stated s/he has not seen any manager in the MCC during their visits.

In an interview on 06/12/24 at 11:13 am, Witness 3 and Witness 4 (family members) stated they are in the facility once-to-twice per week. If s/he had concerns, they would go the front desk for help. The MT is usually the staff member in charge unless the "front office door is open, then [s/he would] go to them. But they had a change and don't know who is in charge now."

On 06/12/24 at 12:00 pm, Staff 4 was observed to be onsite in the MCC. CS requested Staff 4 provide a written schedule of his/her time onsite.

In an email, dated 06/12/24, Staff 4 indicated s/he worked "remote" during the week "05/22- 05/28".

In an interview on 06/13/24 at 9:00 am, Witness 5 (ODHS OPA) stated the following:

* S/He was notified on or about 05/21/24 via email that Staff 3 will be out and Staff 4 would take over.

* S/He was with the understanding that Staff 4 would be onsite 40 hours.

* S/He did not have the paperwork required of and for times when a new administrator is stepping into the administrator role for Staff 2.

On 06/13/24 at 9:35 am, via telephone, these findings were reviewed with Staff 4. Staff 4 stated his/her team was onsite and s/he was available by phone.

Verbal Plan of Correction:

The Interim Administrator will be onsite in the community 40-hours until the Executive Director returns.

Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to provide a full-time administrator to be onsite 40 hours per week; and the facility failed to post the name of the designated person in charge by shift or whenever the Administrator is out of the facility. Findings include, but are not limited to:

On 06/11/24 at 4:43 pm and on 06/12/24 at 9:04 am, the Compliance Specialist entered the facility and did not observe a licensed administrator to be onsite.

In separate interviews on 06/11/24, Staff 1 (RCC), Staff 5 (CG), Staff 6 (MT), Staff 7 (RCC), Staff 8 (CG), and Staff 9 (CG) stated the following:

* At 4:45pm: "There is no administrator for the [memory care]."

* The previous administrator stepped down two weeks ago.

* If [s/he] doesn't know who's the manager on duty, s/he will go to the med tech.

* At 5:00 pm: "[Staff 4] is available via phone [and] not scheduled to be onsite this week."

* At 5:30pm: "The Administrator is [Staff 3]."

* There was no information provided on who was to fill in when Staff 2 (former MCC Administrator stepped down.

*At 5:45 pm, since Staff 2 stepped down, s/he can't say there's been a licensed administrator onsite for 40 hours.

In an interview on 06/11/24 at 6:55 pm, Staff 4 (Regional Director of Operations) stated the following:

* Staff 3 (Administrator) notified the Department via email on 05/21/24 that s/he would be temporarily absent starting on 05/22/24.

* Staff 3 went out on leave on 05/22/24.

* Staff 3 had an exception [to be administrator] for ALF and MCC.

* S/He was in charge when Staff 3 went out on leave.

* Staff 2 stepped down on 05/28/24.

* S/He is onsite every week.

* Last week, s/he was onsite for a full three days and partially on a fourth day and completed two evaluations for assisted living and one evalution for memory care.

When asked what actions were taken with facility staff when Staff 3 stepped down, Staff 4 was unable to provide an answer.

On 06/11/24 at 7:35 pm, there were no waivers or exceptions granted or provided that allowed the facility to operate without an administrator.

On 06/11/24 at approximately 4:45 pm, it was observed in both the ALF and MCC, the facility's required Designated Person in Charge signage stated "Health Care Coordinator" but lacked the name of the staff member in charge. By 7:35 pm, the signage was updated with a name.

On 06/12/24 at 9:05 am, it was observed there was no administrator onsite and the assisted living facility's required Designated Person in Charge signage said "Health Care Coordinator" but lacked the name of the staff member in charge. At 9:16 am, there was no administrator onsite and the MCC facility's required Designated Person in Charge signage was blank.

In separate interviews on 06/12/24, Staff 10 (MT), Staff 11 (CG), Staff 12 (CG) and Staff 13 (LPN) stated the following:

* S/He identified the RCCs or nurses as the person in charge.

* At 9:16 am: "[Staff 2 (former MCC Admin)] stepped down in the end of May."

* S/He stated the RCC was in charge when Staff 2 stepped down.

* Staff 4 was in the MCC last week when s/he asked about the service plan binder.

* S/He did not have Staff 4's contact information.

* The previous memory administrator, before Staff 2, left that role in February 2024.

* There was no communication to care staff who was filling in as interim Administrator.

* Staff 4 spent his/her time last week in Staff 3's office.

* Before [Staff 3] went out on leave, s/he sent an email to facility management who would be in charge, but nothing was communicated to the caregivers.

* Last week [Staff 4] was onsite three to four days for approximately 10 hour days.   

In an interview on 06/12/24 at 10:38 am, Witness 1 and Witness 2 stated s/he has not seen any manager in the MCC during their visits.

In an interview on 06/12/24 at 11:13 am, Witness 3 and Witness 4 (family members) stated they are in the facility once-to-twice per week. If s/he had concerns, they would go the front desk for help. The MT is usually the staff member in charge unless the "front office door is open, then [s/he would] go to them. But they had a change and don't know who is in charge now."

On 06/12/24 at 12:00 pm, Staff 4 was observed to be onsite in the MCC. CS requested Staff 4 provide a written schedule of his/her time onsite.

In an email, dated 06/12/24, Staff 4 indicated s/he worked "remote" during the week "05/22- 05/28".

In an interview on 06/13/24 at 9:00 am, Witness 5 (ODHS OPA) stated the following:

* S/He was notified on or about 05/21/24 via email that Staff 3 will be out and Staff 4 would take over.

* S/He was with the understanding that Staff 4 would be onsite 40 hours.

* S/He did not have the paperwork required of and for times when a new administrator is stepping into the administrator role for Staff 2.

On 06/13/24 at 9:35 am, via telephone, these findings were reviewed with Staff 4. Staff 4 stated his/her team was onsite and s/he was available by phone.

Verbal Plan of Correction:

The Interim Administrator will be onsite in the community 40-hours until the Executive Director returns.

Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the facility failed to fully implement and update an acuity based staffing tool. Findings include, but are not limited to:

A. In an interview on 06/12/24, Staff 4 (Regional Director of Operations) stated the facility used the state's ODHS ABST and the facility is home to 17 residents.

Review of the facility's posted staffing plan indicated the following:

* Day shift (6am - 2pm): one medication technician (MT), three CG, half (.5) Activity Worker, and half (.5) "other workers";

* Swing shift (2pm - 10pm): one MT, two and quarter (2.25) CG, half (.5) Activity Worker, and half (.5) "other workers"; and

* Night shift (10pm - 6am): one MT and one CG.

B.  A review of the facility's ABST with Staff 4, indicated the following:

* There were 22 ADLs listed.

* A staffing plan did generate a 24-hour staffing plan.

* A total of ten residents' profiles had not been updated/reviewed in the last quarter as evident by the last edit date of 02/06/24,  02/07/24, and 03/01/24.

A review of Residents 1, 2, and 3's records and ABST profiles indicated the following:

* Resident 1's service plan, dated 05/08/24 and updated 06/11/24, indicated in the area of "transferring" was updated on 06/07/24, directed staff s/he required "one-person assistance with all transfers as tolerated" and "may occasional 2-person assistance especially while dressing or toileting".

* A progress note entered on 06/11/24 as a part of monitoring Resident 1 for return from hospital on 06/07/24 indicated "Resident is usually requiring 2-person assist, unable to ambulate on [his/her] own..... unable to follow simple commands."

* Resident 1's profile was lasted edited on 05/13/24 and lacked any time dedicated for transfers and the time needed to additional-second staff member.

* Resident 2's service plan, dated 05/02/24, indicated s/he was at risk for falls, elopement, required reminders for eating, and experienced behaviors. In the area of behaviors, staff were directed to "anticipate behaviors... redirect with an activity, snack/fluids, or redirect to a quiet space for one-on-one."

* Resident 2's profile was lasted edited on 03/18/24 and lacked any time dedicated for safety checks and fall preventions, assistance with leisure activities, and supervising/cueing while eating.  

* Resident 3's service plan, dated 05/06/24 and updated 06/10/24, indicated the area of "eating" was revised on 06/11/24. S/He required "cueing/encouragement w/meals....Staff to provide hands on assistance with feeding..."

* An Interim Service Plan and progress note, dated 06/08/24 and entered at 2:09 pm, indicated "staff to provide cueing/encouragement... including hands on assistance with meals."

* Resident 3's profile was last edited on 02/06/24, and lacked any increase in the allotted care time in the area of eating to account for the time required to provide hands-on feeding assistance.

A review of the facility's activity calendar, dated June 2024, indicated on 06/12/24, six different activities were scheduled including exercise time, walking club, bingo, daily chronicles.

On 06/12/24, the Compliance Specialist observed the following:

* No scheduled communal or individual-resident focused activities occurred.

* There were two CGs and one MT on duty.

* At 11:43 am, while Staff 11 (CG) provided assistance in the dining room and Staff 12 (CG) was in a resident's apartment to provide toileting assistance, Resident 4 was observed walking while hunched over his/her walker. Staff 10 (MT) intervened and called twice via radio for assistance, "before [the resident] falls." The resident then fell to his/her knees prompting Staff 10 to announce: "too late." Staff 11 responded to the request, resulting in the dining room meal service to be halted and the dining room unsupervised.

* At 11:50 am, Resident 2 exited the dining room after minimal consumption of soup, soda, and fruit punch. Resident 2 proceeded to pace in his/her wheelchair in common area living room and hallway, crying, checking exit door handles, yelling at other residents. At 12:01 pm, Staff 10 addressed Resident 2's behavior by reminding him/her not to talk to other residents in that way. At which time, Staff 10 moved Resident 2 to the end of the hall away from all persons. At 12:17 pm, Staff 10 is looking for Resident 2 but wasn't down the hall where Staff 10 last saw him/her or in any apartments. CS observed Staff 10 locate Resident 2 banging on the exterior courtyard gate.

* Residents 1, 2, and 3 were dressed in clean clothing appropriate for time of day and season and slip-resistant socks; were free of unpleasant odors, and their hair was groomed.

C. A review of staff schedule, dated 06/01/24 through 06/30/24, timecards, dated 06/01/24, 06/04/24 through 06/08/24, indicated on a total of six different days, or 7 different shifts, in which the facility did not meet their staffing plan.

D. In separate interviews on 06/11/24 and 06/12/24, Staff 5 (CG), 6 (MT), 8 (CG), 9 (CG), 10, 11, and 12 stated the following:

* Showers were provided for these days and were provided unless the resident refused.

* S/He had no concerns with their ability to meet residents needs when staffed with three caregivers.

* S/He had not received any reports of needs being missed or complaints related to quality of care.

In an interview on 06/12/24 at 11:13 am, Witness 3 and 4 stated they rated their satisfaction with the quality of care at the facility as "very good".

On 06/12/24, these findings were reviewed with and acknowledged by Staff 4.

The facility failed to fully implement and update an acuity based staffing tool.

Based on observation, interview, and record review, conducted during a site visit on 06/11/24 and 06/12/24, it was confirmed the faciltiy failed to individually identify resident's rooms to assist residents in recognizing their room for 1 of 1 sampled resident (#2). Findings include, but not limited to:

A review of the facility's resident roster, dated 06/11/2024, indicated what apartment belonged to Resident 2.

Throughout the site visit, the Compliance Specialist observed Resident 2's apartment lacked any identifiable information that would assist Resident 2 with recognizing his/her apartment.

In an interview on 06/12/24 at 2:00 pm, Staff 4 (Regional Director of Operations) stated residents' names should be on their memory boxes, but sometimes residents take them down.

On 06/12/24, these findings were reviewed with and acknowledged by Staff 4. No further information provided.

The faciltiy failed to individually identify resident's rooms to assist residents in recognizing their room.