Print Inspection: FC8K

Based on observation and interview, conducted during a site visit on 10/16/23,  it was confirmed the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include, but are not limited to:

At 12:09 pm on 10/16/23, a brown sticky substance was observed on the floor of a shared resident bathroom in Flower House and a bowel movement was in the toilet. When the Compliance Specialist returned at 2:06 pm the substance was still on the floor and the bowel movement was in the toilet.

During an interview on 10/16/23, Staff 1 (Executive Director) stated each house does not have housekeeping daily and caregivers are responsible for cleaning as needed.

The findings were reviewed with Staff 1 on 10/16/23.

It was confirmed the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents

Verbal plan of correction: Facility to review  daily housekeeping responsibilities with front line staff on 10/18/23. The facility implemented the Resident Care Connections (Manager Rounding Tool) and the daily house assignments for the management team on 10/17/23.

Based on interview and record review, conducted during a site visit on 10/16/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:

In an interview on 10/16/23, Staff 1 (Executive Director) stated the facility used the ODHS tool. The facility's current census was 51 residents, and s/he was unaware four residents were not entered into the tool.

A review of the facility's ODHS ABST on 10/16/23 indicated the facility had 47 residents entered in the ABST.

A review of the current resident roster had the facility's census listed as 51.

The facility failed to fully implement and update an Acuity Based Staffing Tool.

The findings of the investigation were reviewed with and acknowledged by Staff 1 on 10/16/23.

Based on observation, interview and record review, conducted during a site visit on 10/16/23, it was confirmed that the facility failed to provide an accessible outdoor recreation area. Findings include, but are not limited to:

A review of the facility's "Inclement Weather Policy", dated 08/01/21, indicated exterior doors and courtyard doors will be locked in accordance with state regulations. The procedure defined inclement weather as: icy, stormy, extreme heat, snow, etc. at which point the courtyard doors are to remain locked for resident safety. The Inclement Weather policy and procedure for unlocking doors to the courtyard indicated the courtyard doors are to be unlocked upon arrival of day shift and locked at dusk.

In an interview on 10/16/23, Staff 5 (Caregiver) stated if a resident wants to go outside s/he can ask a staff member to put the code in to the house doors and then to come back inside the resident must knock on a house door to be let back inside. Staff 5 also stated "the great-room's doors are usually unlocked."

On 10/16/23, from 9:00 am - 4:00 pm, the Compliance Specialist observed the following:

* The door in Mountain house that led to the main courtyard was locked.

* The door in River house that led to the main courtyard was locked.

* The door in Flower house that led to the main courtyard was locked.

* The door in Lighthouse house that led to the main courtyard was locked.

* The two sets of double doors that lead to the main courtyard and is connected to the common area of all the houses were locked.

* The exit door across from the entry to River house that lead to the main courtyard was locked.

* The exit door across from the entry to Mountain house that lead to the main courtyard was unlocked.

*  When the CS attempted to re-enter the the facility through the courtyard, it was observed all doors to re-enter the facility were locked, except the door across from Mountain House.

* At 12:35 pm, Resident 1 was observed in the outdoor courtyard trying to enter through locked doors, staff from Resident 1's house escorted resident inside from the outdoor courtyard to his/her appropriate dining area.

On 10/16/23 from 9:00 am - 4:00 pm, residents were observed attempting to exit into the courtyard or asked aloud to go outside. CS observed staff did not assist residents with accessing the outdoor courtyards and did not unlocked the doors allowing for residents to come and go freely. On 10/16/23 throughout the site visit the weather was observed to be cool with some rain showers.

The facility failed to provide an accessible outdoor recreation area.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director) on 10/16/23.

Verbal Plan of Correction:

The Executive Director has reached out to the previous maintenance director for the instructions on how to set up the auto unlock/lock timing settings for the doors and they will get the doors set up to automatically unlock during daylight hours.