Print Inspection: FXZD

Based on observation and interview, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to provide three daily nutritious, palatable meals for 4 of 4 sampled residents (#s 2, 6, 13 and 14). Findings include, but are not limited to:

The morning and noon meals were observed on 01/08/24.

During the morning meal, meals were delivered on a rolling preparation cart that was not insulated or enclosed at 8:37 am. Meals were served on Styrofoam plates with a red Cambro insulator, paper napkins and plastic cutlery. Hot and cold food were served on the same plate. The cart with residents' morning meals was observed unattended for over 15 minutes while a CG was feeding a resident. The temperature of the last meal served off the cart was taken when delivered to the resident at 9:08 am and scrambled eggs were 95 degrees.

The noon meal was observed and temperature was taken of the pork served to the last resident off the cart. The pork was 103 degrees.

A sample tray was ordered for the noon meal. The temperature of the pork on the sample tray was 106 degrees. The pork was cold and chewy when eaten.

During separate interviews on 01/08/24 Resident 2, Resident 6, Resident 13 and Resident 14 all stated the food was consistently served cold.

During an interview on 01/08/24 Staff 14 (Dietitian) stated that s/he ordered a test tray monthly as part of an audit, but did not take temperature of food given to residents. A copy of the report was requested, but was not provided.

The facility failed to provide three daily nutritious, palatable meals.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of Correction: The facility to increase number of times temperatures were taken during meal service, on steam table, and throughout service to be done by cook. Education to dietary department was to be provided. Facility would ensure food would not be plated until staff were available to deliver meals. Facility to ensure cold and hot food were served separate. Facility had dietary aides added to contract as of 01/01/24 and was recruiting for two more dietary aides.

Based on observation and interview, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to provide three daily nutritious, palatable meals for 4 of 4 sampled residents (#s 2, 6, 13 and 14). Findings include, but are not limited to:

The morning and noon meals were observed on 01/08/24.

During the morning meal, meals were delivered on a rolling preparation cart that was not insulated or enclosed at 8:37 am. Meals were served on Styrofoam plates with a red Cambro insulator, paper napkins and plastic cutlery. Hot and cold food were served on the same plate. The cart with residents' morning meals was observed unattended for over 15 minutes while a CG was feeding a resident. The temperature of the last meal served off the cart was taken when delivered to the resident at 9:08 am and scrambled eggs were 95 degrees.

The noon meal was observed and temperature was taken of the pork served to the last resident off the cart. The pork was 103 degrees.

A sample tray was ordered for the noon meal. The temperature of the pork on the sample tray was 106 degrees. The pork was cold and chewy when eaten.

During separate interviews on 01/08/24 Resident 2, Resident 6, Resident 13 and Resident 14 all stated the food was consistently served cold.

During an interview on 01/08/24 Staff 14 (Dietitian) stated that s/he ordered a test tray monthly as part of an audit, but did not take temperature of food given to residents. A copy of the report was requested, but was not provided.

The facility failed to provide three daily nutritious, palatable meals.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of Correction: The facility to increase number of times temperatures were taken during meal service, on steam table, and throughout service to be done by cook. Education to dietary department was to be provided. Facility would ensure food would not be plated until staff were available to deliver meals. Facility to ensure cold and hot food were served separate. Facility had dietary aides added to contract as of 01/01/24 and was recruiting for two more dietary aides.

Based on observation, interview and record review, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to implement a service plan that reflects the resident's needs for 1 of 1 resident (# 9). Findings include, but are not limited to:

A review of Resident 9's service plan, dated 12/08/23, indicated resident will call for assistance. Under "Environmental Factors Assistance" the service plan indicated:  "Resident requires extra assistance to assure all personal items are within easy reach and may need to call for additional assistance if [s/he] needs help retrieving an item. [His/Her] hands are partially atrophied..."

On 01/08/24 at 12:07 pm, Resident 9 was observed to be yelling for staff assistance from his/her room.

In an interview on 01/08/24, Resident 9 stated s/he usually yells for help if s/he is unable to locate his/her call button, but staff aren't very responsive.

Resident 9 attempted to locate his/her call button but was unable to find it. Compliance Specialist (CS) observed his/her call button to be located above his/her right shoulder next to his/her neck. Resident 9 stated s/he was unable to reach the call button in its current location. Resident 9 was asked if they would like their call button moved. Resident 9 stated they would like it moved to his/her chest. CS placed the call button within reach.

On 01/09/24 at 12:53 pm, a caregiver was observed leaving Resident 9's room. Resident 9 was observed to be laying in bed with his/her bedside table tray table covering his/her arms. Resident 9 was asked if s/he is able to reach his/her call light and s/he said no because of the "lump". S/He could not move his/her arms because the bedside tray table was on top of them. Resident 9 was asked if the bedside table was moved out of the way would s/he be able to reach her call pendant and s/he said yes. The table was moved and s/he was able to lift his/her arm to his/her chest to press the pendant. S/He said s/he will yell if s/he needs to but people don't come sometimes.

The facility failed to implement a service plan that reflects the resident's needs.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of Correction: A new call button was just purchased for Resident 9 so s/he can press his/her arm on it, and it is used like a door bell, it will be placed on resident's side rail ASAP so Resident 9 always has access to it from his/her bed.

Based on interview and record review, conducted during a site visit on 01/08/24 through 01/09/24, it was confirmed the facility failed ensure service plan was reflective of the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

A review of Resident 2's service plan, dated 12/04/23, indicated resident was a one-person hands-on assist with bathing. Resident preferred showers on Mondays and Thursday evenings. Showers were scheduled per service plan for Mondays and Thursdays morning.

A review of facility shower schedule indicated Resident 2 was scheduled for showers on Mondays and Thursdays at 10:30 am.

A review of Resident 2's shower refusal forms and resident shower/skin report forms, dated 02/01/23 - 01/09/24, indicated there were five shower refusals dated 06/22/23, 10/30/23, 12/14/23, 12/15/23 and 12/25/23, and four  refusals were signed by the resident. There was one completed resident shower/skin report form dated 02/10/23 completed.

A review of Resident 2's progress notes, dated 10/01/23 - 11/30/23, indicated no showers or refusals were documented.

In an interview on 01/08/24, Resident 2 stated s/he has gone 32 and 45 days without showers in the last year. No one even asked during some of those times. S/He wasn't even on the shower schedule for some time. S/He can go all day without seeing someone. His/her showers were on Monday or Tuesday and Thursday or whenever they want. The last shower Resident 2 received was a week ago Saturday. S/He was offered a shower on Thursday but said no because lunch was being brought and s/he had home health coming right after.

In an interview on 01/09/24, Staff 13 (Caregiver) stated Resident 2 refused his/her shower yesterday.

In an interview on 01/09/24, Staff 1 (Administrator) stated Resident 2 frequently refuses showers and staff are supposed to fill out refusal forms to document refusals.

The facility failed to ensure service plan was reflective of the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of Correction: The facility was to implement a system to appropriately document refusals of showers, as well as coordinating shower times consistent with resident preferences and having multiple people attempt to offer showers for residents who refuse.

Based on observation, interview and record review, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 1 sampled residents (# 14). Findings include, but are not limited to:

A review of Resident 14's service plan dated 10/15/23 indicated staff are to assist with compression socks around 1:00 pm.

In an interview on 01/08/24, Resident 14 stated staff did not help him/her with compression stockings. S/he should have his/her compression stockings put on daily around 1:00 pm but most people didn't know how to do it so it happened maybe once a week. S/he was also supposed to be transferred into his/her chair every day for a couple hours so s/he could get out of bed, but that also only happened once a week. Last Thursday was his/her last shower, and last use of compression stockings. S/he insisted that staff put his/her laundry away.

On 01/08/24 at 1:45 pm,  Resident 14 was observed to not have compression stockings on.

In an interview on 01/09/24, Resident 14 stated staff did not put his/her compression stockings on at all on 01/08/24.

The facility failed to ensure the implantation of services.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of Correction: Facility was actively hiring and was to be staffed to their contract within two weeks.

Based on interview and record review conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to assess for and monitor change in conditions for 1 of 1 sampled resident (# 8). Findings include, but are not limited to:

A review Resident 8's service plan, dated 07/25/23, MAR, dated October 2023, and physician orders, and progress notes, dated 09/01/23 through 10/18/23, indicated the following:

·The service plan in the area of skin monitoring directed staff to monitor residents skin for any signs of new or changing skin conditions;

·Progress note, dated 10/01/23, indicated resident had an open wound on his/her "right side lower back" and wound was cleaned and a bandage applied;

·Alert Charting note, dated 10/07/23, indicated "staff will continue to monitor" wound on backside;

·Alert Charting note, dated 10/09/23, indicated Med tech requested RN to look at the wound;

·Nurse's Note, dated 10/09/23, indicated a "Wound/Skin Assessment" entered by Staff 4 (RN) indicated an assessment of Resident 8's open wound was completed;

·Progress note, dated 10/12/23 at 10:05 am, indicated resident received new orders for decubitus ulcer;

·Nurse's Note, dated 10/13/23, indicated a "Change in Condition" entered by Staff 4 indicated resident had experienced a change in condition including increased difficulty swallowing medications, moving less, staying in recliner more which has led to a stage 2 pressure ulcer;

·Physician orders directed treatment for wound care on lower back to be carried out two times per day was initiated on 10/13/23;

·The MAR indicated wound care began in the evening of 10/13/23; and

·On 10/15/23 there is no indication that wound care was completed at 10 am.

In an interview on 01/09/24, Staff 4 stated Resident 8 had a chronic decubitus ulcer on his/her backside. Staff 4 stated s/he had a conversation with Resident 8's family suggesting that the ulcer was due to sleeping in his/her recliner. The facility tried different dressings until physician orders were received and then Staff 4 worked with home health on trying to get resident a different bed to help offload from the wound site.

The facility failed to assess for and monitor change in conditions.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility verbal plan of correction: The facility RN had been through courses on change of conditions. The facility had an LPN in place and staff had been monitoring and reporting skin. Skin conditions were decreasing. The facility was to have a treatment aid starting the following week.

Based on interview and record review, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 5 of 5 sampled resident (# 5, 7, 11, 13, 14) who received insulin injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to:

In an interview on 01/08/24, Staff 4 (RN) stated s/he had been instructed to complete delegations with each staff member having one document that contained all residents with delegated tasks by the regional RN.

In an interview on 01/09/24, Witness 1 (OSBN Liaison) confirmed delegations must be completed in a one-to-one manner, one staff member to one resident for one delegated task.

A review of the facility's delegation binder indicated that six med techs had been delegated to and each med tech had a single document containing six residents names that required delegated tasks regarding subcutaneous insulin injections. No documented delegations were provided for the use of a glucometer for any staff member.

the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 on 01/09/24.

Facility Written Plan of Correction: The Registered Nurse had been in-serviced on delegation process according to OARs and was completed 01/08/24. The registered nurse was to administer all insulins until delegations were completed. Within 10 calendar days, the registered nurse was to re-delegate all med techs to be completed by 01/18/24. The Administrator or designee was to review delegations every 60 days or as needed.

See findings in C0282, C0301, C0303 and C0310.

Facility Verbal Plan of correction: RN Will follow up with the provider about the orders for nebulizer and inhaler. MT training on ordering medications and corrective actions with MT if "meds not available" documented and provide training to document interventions to get meds in building by 1/15/23.  Clinical meeting to re-start 1/10/23 and will review prog notes, incident reports, MAR exceptions, PRN effectiveness and 24 hour alerts and review physician orders 5 days/week.

Based on interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:

A review of Resident 4's May 2023 MAR and progress notes indicated the following:

·  On 05/21/23 a progress note entered at 8:54 pm, indicated during the 3:00 pm medication pass Staff 15 (Former med tech) observed Resident 4 taking medications. When Staff 15 asked the resident what s/he was taking Resident 4 stated s/he was taking his/her morning medications, and that s/he had forgotten to take them.

·MAR indicated on 05/21/23, Resident 4's scheduled 5:00 pm Risperidone (psychotropic) and Trifluoperazine (psychotropic) held due to a medication error.

In an interview on 01/09/24, Staff 1 (Administrator), Staff 2 (Regional Director of Operations) and Staff 3 (Assistant Executive Director) stated Resident 4 now waited with his/her walker by the med cart when his/her medications were due. There was also a med tech training that occurred after this incident for staff to visually observe residents take medications.

The facility failed to ensure the staff person who administers the medication must visually observe the resident take the medication.

The findings were reviewed with and acknowledged by Staff 1, Staff 2, Staff 3 and Staff 4 (RN) on 01/09/24.

Facility verbal Plan of Correction: The facility provided a staff training after the incident to observe residents take medications.

Based on interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 5). Findings include, but are not limited to:

A review of Resident 5's June 2023 MAR and physician orders indicated the following:

·Resident to receive Lantus, 14 units as a subcutaneous injection every morning and hold for CBG less than 80;

·On 06/04/23 at 9:09 am Lantus not given due to medication not in facility and facility ordered stat.

In an interview on 01/09/24, Resident 5 stated s/he did not recall the facility running out of his/her insulin, "but it's possible."

The facility failed to carry out medication orders as prescribed.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility verbal plan of correction: RN will follow up with the provider about the orders for nebulizer and inhaler. MT training on ordering medications and corrective actions with MT if "meds not available" documented and provide training to document interventions to get medications in building by 01/15/24.  Clinical meeting to re-start 01/10/24 and was to review progress notes, incident reports, MAR exceptions, PRN effectiveness and 24 hour alerts and review physician orders 5 days/week.

Based on interview and record review, conducted during a site visit on 01/08/24 through 01/09/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 7). Findings include, but are not limited to:

A review of Resident 7's 10/01/23 - 10/31/23 MAR and physician orders indicated the following:

·Physician ordered Ozempic, 0.5mg, subcutaneous injection once per week for diabetes;

·MAR indicated on 10/10/23 Ozempic not available;

·On 10/17/23, 10/24/23 and 10/31/23, there was no indication that the Ozempic injection was administered.

A review of facility Incident Report indicated Resident 7 did not receive his/her Ozempic injection on 10/31/23.

In an interview on 01/09/24, Resident 4 stated s/he did not receive his/her Ozempic a while back because there were not staff delegated to give those shots.

The facility failed to carry out medication orders as prescribed.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of correction: The facility RN was to follow up with the provider about the orders for nebulizer and inhaler, MT training was to be provided on ordering medications and corrective actions to be taken with MT if "meds not available" was documented and provide training to document interventions to get medications in the building by 01/15/24.  Clinical meetings were to re-start 01/10/24 and were to review progress notes, incident reports, MAR exceptions, PRN effectiveness and 24 hour alerts and review physician orders five days a week.

Based on interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to carry out medication orders as prescribed for 3 of 3 sampled residents (#s 9, 11, &12). Findings include, but are not limited to:

A review of Resident 9's 11/01/23 - 11/30/23 MAR and physician orders indicated:

·Order for Melatonin (a sleep aid) one tab by mouth at night;

·MAR indicated medication not available on 11/14/23, 11/16/23, 11/17/23, 11/18/23 and 11/19/23;

·Order for Albuterol HFA inhale 2 puffs by mouth every four (4) hours as needed for dyspnea/ shortness of breath;

MAR indicated Albuterol not administered for 11/01/23 - 11/30/23;

·Order for Iprat/Albut to inhale 3ml via nebulizer every six (6) hours as needed for wheezing or dyspnea due to asthma. Use if albuterol inhaler is ineffective;

·Iprat/Albut order effective date 10/30/23 and discontinued on 11/16/23. New order for Iprat/Albut start date 11/30/23;

·MAR indicated Iprat/Albut added on 11/03/23, scheduled for 8:00 am, 12:00 pm, 5:00 pm and 9:00 pm, first administration on 11/05/23 at 5:00 pm;

·MAR indicated Iprat/Albut was administered 38 times by the facility after being discontinued on 11/16/23.

In an interview on 01/09/24, Staff 4 (RN) stated Resident 9's physician had access to the facility's MAR system and was making changes within the system for Resident 9's medications.

A review of Resident 11's 11/01/23 - 11/30/23 MAR and physician orders indicated:

·Physician order for Divalproex Sodium for bipolar disorder, one (1) tablet by mouth every morning and an order for three (3) tablets by mouth revery evening;

·MAR indicated morning dose of Divalproex Sodium was unavailable on 11/03/23 and evening dose unavailable on 11/14/23;

·Physician order for Furosemide one (1) tablet by mouth by mouth every day for heart condition;

·MAR indicated on 11/28/23 resident was out of Furosemide;

·Physician order for propranolol 1 tablet by mouth twice daily for hypertension;

·MAR indicated on 11/02/23 propranolol not administered being mailed from pharmacy;

·Physician order for Vitamin D3, a capsule by mouth everyday;

·MAR indicated on 11/12/23 Vitamin D3 not available;

·Physician order for Zinc Oxide 20% ointment to be applied in a thick layer over right buttocks 2 times daily; and

·MAR indicated on 11/28/23 8am dose of Zinc Oxide not administered due to not being able to locate.

In an interview on 01/09/24, Resident 11 stated the facility did run out of his/her medications and sometimes s/he had trouble getting his/her PRN medications when requested.

A review of Resident 12's 11/01/23 - 11/30/23 MAR and physician orders indicated the following:

·Physician order for Diclofenac 1% gel to apply 4 grams topically 3 times daily;

·MAR indicated Diclofenac was unavailable on 11/28/23 at 8am and 11/29/23 at 5pm;

·Physician order for Losartan (high blood pressure) 100mg tab by mouth every day;

·MAR indicated on 11/14/23 Losartan unavailable;

·Physician order for Oxycodone 10 mg tab, 1 tablet by mouth twice daily. Scheduled dose to be given 30-60 minutes prior to wound care. May also take 1 tablet by mouth as needed for pain (4 hours between doses), last does to be given prior to sleep.

·MAR indicated on 11/13/23 and 11/25/23 resident received his/her 2 scheduled doses as well as 3 PRN doses of Oxycodone; and

·MAR further indicated on 11/10/23, 11/12/23, 11/13/23, 11/17/23, 11/25/23 and 11/26/23 oxycodone was administered less than 4 hours between doses.  

The facility failed to carry out medication orders as prescribed.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility verbal plan of correction: RN was to follow up with the provider about the orders for nebulizer and inhaler. MT training was to occur for ordering medications and corrective actions with MT if "meds not available" documented and provide training to document interventions to get medications in building by 01/15/23.  Clinical meeting to re-start 01/10/23 and will review progress notes, incident reports, MAR exceptions, PRN effectiveness and 24-hour alerts and review physician orders 5 days/week.

Based on interview and record review, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to keep an accurate MAR for 2 of 2 sampled residents (#s 11 and 13). Findings include, but are not limited to:

In an interview on 01/09/24, Staff 6 (med tech) stated Staff 7 (med tech) had been delegated to by the facility RN during the morning medication pass on 01/09/24. Staff 6 stated s/he had been delegated for several residents during the afternoon medication pass on 01/09/24 and would receive the rest of the delegations for residents during the evening medication pass on 01/09/24. Staff 6 stated s/he had not logged out of the computer s/he was using when Staff 7 and the RN documented in the MARs for delegated tasks that morning [01/09/24].

A review of Resident 11 and Resident 13s' 01/01/24 - 01/31/24 MARs indicated both residents' delegated insulin had been administered by Staff 6.

In an interview on 01/09/24, Staff 4 (RN) stated s/he had forgotten to change users on the computer for medication passes when providing delegation teaching on the morning on 01/09/24.

Staff 7 had documented in the MAR as Staff 6.

The facility failed to keep an accurate MAR.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 on 01/09/24.

Facility Verbal Plan of correction: The facility was to complete med tech training to include using correct staff ID's when documenting in MAR.

Based on observation, interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 5 of 5 sampled residents (#s 2, 6, 10, 14 and 15). Findings include, but are not limited to:

On 01/08/24 at 10:32 am, Resident 14 was observed to press his/her call light button. At 10:46 am, a staff member was observed to answer the call light and asked for assistance from another staff member to provide incontinence care. It took a total of 20 minutes and 43 seconds for two staff members to respond to the resident's call light to assist resident with incontinence care.

A review of Resident 14 call light logs for 01/08/24, indicated Resident 14 used his/her call light 12 times and three of those calls took longer than 20 minutes for staff to respond to, varying from 21 minutes to 54 minutes.

A review of call lights logs, dated 01/05/24 - 01/08/24, for Residents 2, 6 and 10 indicated:

* Resident 2 had 11 instances of call lights over 20 minutes;

* Resident 6 had nine instances of call lights over 20 minutes; and

* Resident 10 had four instances of call lights over 20 minutes.

In an interview on 01/08/24, Resident 2 stated s/he has gone all day without seeing a staff member.

In an interview on 01/08/24, Staff 8 (med tech) stated the facility was short staffed [on 01/08/24].

In an interview on 01/08/24, Resident 14 stated s/he frequently waited 30 minutes to an hour for staff to respond to his/her call light.

In an interview on 01/08/24, Resident 6 stated on 11/06/23 there were only 2 caregivers working on swing shift and s/he waited 1-2 hours for staff to respond to his/her call light.

In an interview on 01/08/24, Witness 2 (ODHS Contract Administrator) stated the contract required direct care staff during the day and evening shift to be 0.5 full time employees (FTE) per individual served under the contract and for night shift there needed to be 4 FTE for individuals served under the contract.

In an interview on 01/09/24, Resident 15 stated the facility does not have enough staff and it has taken 2.5 hours for staff to respond to his/her call light before. S/he stated nights and weekends were really bad for staffing.

In an interview on 01/09/24, Resident 10 stated on a bad day it took staff anywhere from 30 minutes to 2 hours to respond.

The resident roster indicated there were 14 residents served under the contract (C wing) at the time of the site visit.

A review of staff assignment sheets, dated 01/08/24 and 01/09/24, indicated the following:

·On 01/08/24 during day shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 3 caregivers were assigned;

·On 01/09/24 during swing shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 5 caregivers were assigned.

The facility was staffed short of the facility contract requirements.

A review of the staff schedules dated 08/01/23 through 01/31/24, indicated the facility was consistently not staffed to the contract requirements. The staff schedule for 11/06/23 indicated there were 2 caregiver and 2 med techs scheduled for swing shift.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of correction: Facility was actively hiring and was to be staffed to their contract within two weeks.

Based on observation, interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 5 of 5 sampled residents (#s 2, 6, 10, 14 and 15). Findings include, but are not limited to:

On 01/08/24 at 10:32 am, Resident 14 was observed to press his/her call light button. At 10:46 am, a staff member was observed to answer the call light and asked for assistance from another staff member to provide incontinence care. It took a total of 20 minutes and 43 seconds for two staff members to respond to the resident's call light to assist resident with incontinence care.

A review of Resident 14 call light logs for 01/08/24, indicated Resident 14 used his/her call light 12 times and three of those calls took longer than 20 minutes for staff to respond to, varying from 21 minutes to 54 minutes.

A review of call lights logs, dated 01/05/24 - 01/08/24, for Residents 2, 6 and 10 indicated:

* Resident 2 had 11 instances of call lights over 20 minutes;

* Resident 6 had nine instances of call lights over 20 minutes; and

* Resident 10 had four instances of call lights over 20 minutes.

In an interview on 01/08/24, Resident 2 stated s/he has gone all day without seeing a staff member.

In an interview on 01/08/24, Staff 8 (med tech) stated the facility was short staffed [on 01/08/24].

In an interview on 01/08/24, Resident 14 stated s/he frequently waited 30 minutes to an hour for staff to respond to his/her call light.

In an interview on 01/08/24, Resident 6 stated on 11/06/23 there were only 2 caregivers working on swing shift and s/he waited 1-2 hours for staff to respond to his/her call light.

In an interview on 01/08/24, Witness 2 (ODHS Contract Administrator) stated the contract required direct care staff during the day and evening shift to be 0.5 full time employees (FTE) per individual served under the contract and for night shift there needed to be 4 FTE for individuals served under the contract.

In an interview on 01/09/24, Resident 15 stated the facility does not have enough staff and it has taken 2.5 hours for staff to respond to his/her call light before. S/he stated nights and weekends were really bad for staffing.

In an interview on 01/09/24, Resident 10 stated on a bad day it took staff anywhere from 30 minutes to 2 hours to respond.

The resident roster indicated there were 14 residents served under the contract (C wing) at the time of the site visit.

A review of staff assignment sheets, dated 01/08/24 and 01/09/24, indicated the following:

·On 01/08/24 during day shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 3 caregivers were assigned;

·On 01/09/24 during swing shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 5 caregivers were assigned.

The facility was staffed short of the facility contract requirements.

A review of the staff schedules dated 08/01/23 through 01/31/24, indicated the facility was consistently not staffed to the contract requirements. The staff schedule for 11/06/23 indicated there were 2 caregiver and 2 med techs scheduled for swing shift.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of correction: Facility was actively hiring and was to be staffed to their contract within two weeks.

Based on observation, interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 5 of 5 sampled residents (#s 2, 6, 10, 14 and 15). Findings include, but are not limited to:

On 01/08/24 at 10:32 am, Resident 14 was observed to press his/her call light button. At 10:46 am, a staff member was observed to answer the call light and asked for assistance from another staff member to provide incontinence care. It took a total of 20 minutes and 43 seconds for two staff members to respond to the resident's call light to assist resident with incontinence care.

A review of Resident 14 call light logs for 01/08/24, indicated Resident 14 used his/her call light 12 times and three of those calls took longer than 20 minutes for staff to respond to, varying from 21 minutes to 54 minutes.

A review of call lights logs, dated 01/05/24 - 01/08/24, for Residents 2, 6 and 10 indicated:

* Resident 2 had 11 instances of call lights over 20 minutes;

* Resident 6 had nine instances of call lights over 20 minutes; and

* Resident 10 had four instances of call lights over 20 minutes.

In an interview on 01/08/24, Resident 2 stated s/he has gone all day without seeing a staff member.

In an interview on 01/08/24, Staff 8 (med tech) stated the facility was short staffed [on 01/08/24].

In an interview on 01/08/24, Resident 14 stated s/he frequently waited 30 minutes to an hour for staff to respond to his/her call light.

In an interview on 01/08/24, Resident 6 stated on 11/06/23 there were only 2 caregivers working on swing shift and s/he waited 1-2 hours for staff to respond to his/her call light.

In an interview on 01/08/24, Witness 2 (ODHS Contract Administrator) stated the contract required direct care staff during the day and evening shift to be 0.5 full time employees (FTE) per individual served under the contract and for night shift there needed to be 4 FTE for individuals served under the contract.

In an interview on 01/09/24, Resident 15 stated the facility does not have enough staff and it has taken 2.5 hours for staff to respond to his/her call light before. S/he stated nights and weekends were really bad for staffing.

In an interview on 01/09/24, Resident 10 stated on a bad day it took staff anywhere from 30 minutes to 2 hours to respond.

The resident roster indicated there were 14 residents served under the contract (C wing) at the time of the site visit.

A review of staff assignment sheets, dated 01/08/24 and 01/09/24, indicated the following:

·On 01/08/24 during day shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 3 caregivers were assigned;

·On 01/09/24 during swing shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 5 caregivers were assigned.

The facility was staffed short of the facility contract requirements.

A review of the staff schedules dated 08/01/23 through 01/31/24, indicated the facility was consistently not staffed to the contract requirements. The staff schedule for 11/06/23 indicated there were 2 caregiver and 2 med techs scheduled for swing shift.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of correction: Facility was actively hiring and was to be staffed to their contract within two weeks.

Based on observation, interview and record review, conducted during a site visit from 01/08/24 through 01/09/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 5 of 5 sampled residents (#s 2, 6, 10, 14 and 15). Findings include, but are not limited to:

On 01/08/24 at 10:32 am, Resident 14 was observed to press his/her call light button. At 10:46 am, a staff member was observed to answer the call light and asked for assistance from another staff member to provide incontinence care. It took a total of 20 minutes and 43 seconds for two staff members to respond to the resident's call light to assist resident with incontinence care.

A review of Resident 14 call light logs for 01/08/24, indicated Resident 14 used his/her call light 12 times and three of those calls took longer than 20 minutes for staff to respond to, varying from 21 minutes to 54 minutes.

A review of call lights logs, dated 01/05/24 - 01/08/24, for Residents 2, 6 and 10 indicated:

* Resident 2 had 11 instances of call lights over 20 minutes;

* Resident 6 had nine instances of call lights over 20 minutes; and

* Resident 10 had four instances of call lights over 20 minutes.

In an interview on 01/08/24, Resident 2 stated s/he has gone all day without seeing a staff member.

In an interview on 01/08/24, Staff 8 (med tech) stated the facility was short staffed [on 01/08/24].

In an interview on 01/08/24, Resident 14 stated s/he frequently waited 30 minutes to an hour for staff to respond to his/her call light.

In an interview on 01/08/24, Resident 6 stated on 11/06/23 there were only 2 caregivers working on swing shift and s/he waited 1-2 hours for staff to respond to his/her call light.

In an interview on 01/08/24, Witness 2 (ODHS Contract Administrator) stated the contract required direct care staff during the day and evening shift to be 0.5 full time employees (FTE) per individual served under the contract and for night shift there needed to be 4 FTE for individuals served under the contract.

In an interview on 01/09/24, Resident 15 stated the facility does not have enough staff and it has taken 2.5 hours for staff to respond to his/her call light before. S/he stated nights and weekends were really bad for staffing.

In an interview on 01/09/24, Resident 10 stated on a bad day it took staff anywhere from 30 minutes to 2 hours to respond.

The resident roster indicated there were 14 residents served under the contract (C wing) at the time of the site visit.

A review of staff assignment sheets, dated 01/08/24 and 01/09/24, indicated the following:

·On 01/08/24 during day shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 3 caregivers were assigned;

·On 01/09/24 during swing shift there was 1 med tech and 1 caregiver assigned for A and B wing of the facility. For C wing 1 med tech and 5 caregivers were assigned.

The facility was staffed short of the facility contract requirements.

A review of the staff schedules dated 08/01/23 through 01/31/24, indicated the facility was consistently not staffed to the contract requirements. The staff schedule for 11/06/23 indicated there were 2 caregiver and 2 med techs scheduled for swing shift.

The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

The findings were reviewed with and acknowledged by Staff 1 (Administrator), Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of correction: Facility was actively hiring and was to be staffed to their contract within two weeks.

Based on interview and record review, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned for 2 of 3 (#'s 8 and 9) sampled staff.  Findings include, but are not limited to the following:

A review of Resident 1's MAR and progress notes for January 2023 indicated the following:

·Resident moved into facility on 01/24/23.

·From 01/24/23 through 01/31/23 Resident 1 was scheduled for four administrations per day of Insulin Lispro Solution on a sliding scale.

·Of the 30 administrations, residents blood sugar was within range to administer insulin six times.

·Resident 1 had five had instances of moderate hypoglycemia when blood sugars were under 70.

·Progress notes indicated three instances in which resident was monitored for low blood sugar and offered snacks to raise his/her blood sugar.

A review of facility binder containing diabetic resident assessments and hyperglycemia and hypoglycemia protocols indicated moderate hypoglycemic occurs when CBGs 70 or less. The protocol is to administer 4oz of juice or 5 packets of sugar dissolved in 4-6oz of water. Blood sugars to be checked every 15-30 minutes and if resident is still hypoglycemic to contact PCP.

In an interview on 01/08/24, Staff 5 (Med tech) stated if resident blood sugars are low, s/he has to document, offer orange juice and a snack to bring blood sugars back to normal, wait 15 to 30 minutes and recheck CBG's. Blood sugar under 70 is considered low. Each resident's chart indicated what signs and symptoms the resident exhibits when hyper/hypoglycemic. S/he further stated s/he could contact the nurse for guidance as well.

In an interview on 01/09/24, Staff 6 (Med tech) stated s/he was given a pamphlet to study for signs and symptoms of hyperglycemia and hypoglycemia. If staff were concerned about a resident the nurse was available to call. Below 70 is considered hypoglycemic.

A review of staff demonstrated competencies for Staff 7 (Med tech), Staff 8 (Caregiver), and Staff 9 (Former med tech) was completed, and 2 of 3 staff did not have demonstrated competencies.

In an interview on 01/09/24, Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) stated it was staffs' responsibility to return their demonstrated competency checklists when the checklists were completed.

The facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned.

The findings were reviewed with and acknowledged by Staff 1, Staff 2, Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of correction: Facility was to audit current staff competencies by 01/23/24. New hires' competencies were to be done by the trainer and with the direct supervisor, with a final check done by Assistant Executive Director. The new system was created 01/09/24 and was being put into place.

Based on observation and interview, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to take measures to prevent the entry of rodents, flies, mosquitoes and other insects. Findings include, but are not limited to:

During the site visit flies were observed throughout the interior of the facility. On 01/08/24 a staff member was observed to exit and re-enter through a side door. Upon reentry the door did not latch, swinging open and left unattended, allowing for the entry of insects.

In an interview with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations) stated the flies started a couple of weeks ago and staff have been unable to determine the source.

The facility failed to take measures to prevent the entry of rodents, flies and mosquitoes and other insects.

The findings were reviewed with and acknowledged by Staff 1, Staff 2, Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Facility Verbal Plan of correction: The facility had residents who collect soda bottles or food at bedside. The facility hired a housekeeper. Education would be provided to residents and staff to bag up bottles and on not propping doors open by 1/30/23.

Based on observation and interview, conducted during a site visit on 01/08/24 and 01/09/24, it was confirmed the facility failed to keep the interior of the facility free from unpleasant odors and clean and in good repair. Findings include, but are not limited to:

Throughout the site visit, strong and pervasive odors were observed in C-wing, and were strongest near room 31. The floors in the dining room were observed to have 1-2 inch gaps between the planks, and carpeting throughout the facility was observed to have large dark stains.

On 01/08/24 between 11:00 am and 11:20 am, the restrooms near rooms 13 and 15 were observed to have brown spots and smears on the toilets and inside of the toilet bowls.

In an interview on 01/09/24, Staff 1 (Administrator) stated a housekeeper was just hired as of 01/08/24 and there was a maintenance worker making repairs in some of the resident rooms.

The facility failed to keep the interior of the facility free from unpleasant odors and clean and in good repair.

The findings were reviewed with and acknowledged by Staff 1, Staff 2 (Regional Director of Operations), Staff 3 (Assistant Administrator) and Staff 4 (RN) on 01/09/24.

Verbal Plan of Correction: Maintenance was working on repairs. New housekeeper hired yesterday 01/08/24 and s/he would do carpet shampooing by the end of the week. If housekeeper was unable, will request from maintenance.  Staff would clean resident wheelchairs 1x/week. Executive Director to do daily rounding 5 days/week and would document to ensure resident rooms with odors were being cleaned.