Print Inspection: HODJ

Based on observation, interview, and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility's failure to implement a smoking policy was substantiated for 1 of 1 sampled resident (# 11). This posed an immediate jeopardy situation that could threaten the health, safety, and welfare of residents. Findings include, but are not limited to:

During separate interviews on 01/28/25 and 01/29/25, Staff 8 (Med Tech), Staff 11 (Caregiver), and Staff 14 (Caregiver) stated Resident 11 was smoking cigarettes in his/her, and they had notified management.

On 01/28/25, at approximately 10:30 am, an ashtray with ash in it and a strong odor of cigarette smoke was observed in Resident 11's room.

On 01/28/25, the facility provided the Department with quarterly smoking assessments for residents identified as smokers. A smoking assessment for Resident 11 was not included.

A risk agreement for Resident 11, dated 01/30/24, indicated s/he had been smoking in his/her room and care partners were to assist Resident 11 outside if s/he wanted to smoke. The risk agreement indicated it was to be reviewed on 02/30/24. There was no documented evidence the risk agreement had been reviewed.

Chart notes for Resident 11, dated 04/20/24, indicated staff had reported Resident 11 smoking in his/her room.

A "Smoking Safety Plan" for Resident 11, undated, indicated "lighters, matches, and cigarettes should be securely stored by staff and only made available during supervised smoking time."

On 01/28/25, Staff 3 (Executive Director) stated residents were "not suppose" to smoke in their rooms but s/he had been told they do. S/he further stated the facility had not removed lighters or cigarettes from Resident 11's room.

On 01/28/25 at approximately 7:30 pm, the facility submitted a written plan of correction indicating the facility was instituting safety checks four times a shift to ensure Resident 11 was not smoking in his/her room, and posted a room inspection check-off sheet on Resident 11's door for staff to document they had performed the checks. The plan of correction further indicated service plans would be made available to staff.

On 01/29/25, at approximately 3:06 pm, only three signatures were observed on the check-off sheet for day shift, which ended at 2:30 pm.

On 01/29/25, at approximately 3:14 pm, Resident 11 stated s/he had smoked in his/her room that day.

On 01/29/25, at approximately 3:20 pm, Staff 15 (Caregiver) stated s/he was unaware of any new temporary service plans increased monitoring for any residents.

On 01/29/25, at approximately 3:20 pm, Staff 12 (Med Tech) stated there was no new temporary service plan for Resident 11.

On 01/28/25, Staff 6 (Med Tech) stated care staff do not have access to resident service plans if they are not in the service plan binder in the break room.

On 01/29/25, no temporary service plan was observed for Resident 11 in the break room.

The facility's failure to implement a smoking policy was substantiated. This posed an immediate jeopardy situation that could threaten the health, safety, and welfare of residents.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4 (Wellness Director, LPN), and Staff 5 (Resident Care Coordinator) on 01/31/25.

The Department received and accepted a written plan of correction on 01/28/25 at approximately 7:30 pm.

Based on interview and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility's failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse was substantiated for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

An incident report, dated 05/03/24, indicated Resident 2 had suffered an unwitnessed fall with injury and was unable to tell staff what had happened. There was no documented evidence the facility had investigated or reported the unwitnessed fall with injury to the local Seniors and People with Disabilities (SPD) office.

On 01/31/25, Staff 4 (Wellness Director, LPN) stated the incident had not been investigated by the facility.

The facility's failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4, and Staff 5 (Resident Care Coordinator) on 01/31/25.

Verbal plan of correction: The employees responsible for investigating and reporting the incident were no longer employed by the facility. Executive Director and Wellness Director to review incident reports daily, investigate, and report to the local SPD if necessary.

Based on interview and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility's failure to ensure the implementation of services was substantiated for 2 of 4 sampled residents (#s 1 and 4). Findings include, but are not limited to:

On 01/29/25, Staff 11 (Caregiver) stated the facility tracked resident showers by initialing the facility's shower schedule when showers were completed. S/he further stated staff were to indicate refusals on the shower schedule, and if there was no initial, care staff had forgotten to sign the sheet or the resident had not received a shower.

1. Resident 1's service plan, dated 01/06/25, indicated s/he was to receive assistance with showers. It did not indicate when or how often Resident 1 was to receive assistance with showers.

On 01/31/25, Resident 1 stated s/he was to receive assistance with showers twice a week and had not received a shower "in weeks."  S/He further stated s/he had not left the facility during that time.

The facility's swing shift shower schedule, dated 12/13/24 through 01/19/25, indicated:

·Resident 1 was to receive showers on Tuesdays and Saturdays;

·Resident 1 had been marked as "out" on 12/31/24, 01/07/25, and 01/14/25;

·There were no staff initials for Resident 1's scheduled showers on 12/17/24, 12/21/24, 01/04/25, or 01/11/25; and

·There were no swing shifts shower schedules past 01/19/25.

2. Resident 4's service plan, dated 01/10/25, indicated s/he was to receive full assistance with showers, and staff were to offer Resident 4 showers daily.

On 01/29/25, Resident 4 declined to be interviewed.

The facility's swing shift shower schedule, dated 12/13/24 through 01/19/25, indicated:

·Resident 4 was to receive showers on Mondays and Wednesdays; and

·There were no staff initials for Resident 4's scheduled showers on 12/18/25, 12/30/25, 01/01/25, 01/08/25, 01/13/25, and 01/15/25.

The facility's failure to ensure the implementation of services was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4 (Wellness Director, LPN), and Staff 5 (Resident Care Coordinator) on 01/31/25.

Verbal plan of correction: Verbal POC: Facility to review shower schedule, ensure all residents are on the shower schedule, and Wellness Director will immediately begin reviewing shower schedules daily.

Based on interview and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility's failure to carry out medication orders as prescribed was substantiated for 1 of 1 sampled resident (# 9). Findings include, but are not limited to:

On 01/29/25, Resident 9 stated s/he had not received her inhaler for a week.

A physician order for Resident 9, dated 06/13/24, indicated s/he was to receive Trelegy-Ellipta 100mcg-62.5mcg-25mcg (inhaler) once a day.

Resident 9's MAR, dated 01/01/25 through 01/29/25, indicated s/he had not received his/her Trelegy-Ellipta 100mcg-62.5mcg-25mcg from 01/24/25 through 01/27/25. Notes indicated the facility was "waiting on refill."

On 01/29/25, Staff 4 (Wellness Director, LPN) stated s/he was unaware Resident 9 had been missing medication and the facility was supposed to order medications for residents seven days before the medication ran out.

The facility's failure to carry out medication orders as prescribed was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4, and Staff 5 (Resident Care Coordinator) on 01/31/25.

Verbal plan of correction: Exception list for missed medications to be reviewed daily. Med techs will be retrained to ensure med techs are reordering medications 7 days in advance.

Based on observation, interview and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility ' s failure to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident and adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department was substantiated for 3 of 3 sampled residents (#s 1, 4, and 10). Findings include, but are not limited to:

The facility ' s Personal/Professional Services Contract, dated 10/08/24, indicated the facility was to provide staff solely responsible for residents on specific needs contracts:

·Three caregivers and one med tech on day shift;

·Three caregivers and one med tech on swing shift; and

·Two caregivers and one med tech on night shift.

The facility ' s posted staffing plan indicated totals of:

·Three caregivers and two med techs on day shift;

·Two caregivers and one med tech on swing shift; and

·Two caregivers and one med tech on night shift.

The facility ' s staff schedule, dated 01/19/25 through 01/31/25 indicated:

·" SN "  for staff members responsible for specific needs residents and  " ALF "  for staff members responsible for all other residents;

·The facility scheduled one caregiver and one med tech on night shift, delineated as  " SN; "  and

·One direct care staff delineated as  " ALF. "

The facility had one resident who required two-person transfer assistance and was not on a specific needs contract. The facility would be unable to provide assistance during an evacuation with only one direct care staff assigned to non-specific needs residents.

Staff timecards indicated the facility was not staffed to meet the fire safety evacuation standards as required on 10/10/24, 10/14/24, 11/01/24, 11/04/24, 11/19/24, 11/27/24, 12/01/24, 12/06/24, 12/16/24, 12/17/24, and 01/01/25.

On 01/29/25, Staff 11 (Caregiver) stated:

·S/He was  " not sure "  what the difference was between  " SN "  and  " ALF "  on the schedule and management had never told care staff;

·Staff were  " lucky "  if they were able to get resident ' s laundry done;

·The facility tracked resident showers by initialing the facility ' s shower schedule when showers were completed; and

·Staff were to indicate refusals on the shower schedule, and if there was no initial, care staff had forgotten to sign the sheet or the resident had not received a shower.

Resident 1 ' s service plan, dated 01/06/25, indicated s/he was to receive assistance with showers. It did not indicate when or how often Resident 1 was to receive assistance with showers.

On 01/31/25, Resident 1 stated s/he was to receive assistance with showers twice a week and had not received a shower  " in weeks. "  S/He further stated s/he had not left the facility during that time.

The facility ' s swing shift shower schedule, dated 12/13/24 through 01/19/25, indicated:

·Resident 1 was to receive showers on Tuesdays and Saturdays;

·Resident 1 had been marked as  " out "  on 12/31/24, 01/07/25, and 01/14/25;

·There were no staff initials for Resident 1 ' s scheduled showers on 12/17/24, 12/21/24, 01/04/25, or 01/11/25; and

·There were no swing shifts shower schedules past 01/19/25.

Resident 4 ' s service plan, dated 01/10/25, indicated s/he was to receive full assistance with showers, and staff were to offer Resident 4 showers daily.

On 01/29/25, Resident 4 declined to be interviewed.

The facility ' s swing shift shower schedule, dated 12/13/24 through 01/19/25, indicated:

·Resident 4 was to receive showers on Mondays and Wednesdays; and

·There were no staff initials for Resident 4 ' s scheduled showers on 12/18/25, 12/30/25, 01/01/25, 01/08/25, 01/13/25, and 01/15/25.

On 01/29/25, Resident 10 stated s/he had been  " stuck in bed yesterday "  and had asked staff for assistance at around 9:30 am or 10:00 am but  " there was always some reason they had to do something. "  S/He further stated staff had assisted him/her out of bed at approximately 3:00 pm. Resident 6 stated some staff could get her out of bed by themselves, but others say they need two.

On 01/29/25, Staff 11 stated staff on day shift had been too busy to help Resident 10 out of bed as s/he was a two-person transfer assist.

Resident 10 ' s service plan, dated 01/14/25, indicated s/he required assistance from one staff member to transfer in and out of bed, effective on 01/11/24.

The facility ' s failure to provide direct care staff sufficient in numbers to meet the scheduled and unscheduled needs of each resident and adequate direct care staff present at all times to meet the fire safety evacuation standards as required by the fire authority or the Department was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4 (Wellness Director, LPN), and Staff 5 (Resident Care Coordinator) on 01/31/25.

Verbal plan of correction: Facility to use their Acuity-Based Staffing Tool specific needs staffing requirements, and fire and life safety standards to create schedules going forward and will no longer share staff between recipients of the specific needs contracts and other residents.

Based on interview and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25 the facility ' s failure to fully implement and update an acuity-based staffing tool was substantiated. Findings include, but are not limited to:

The facility had implemented the ODHS ABST. The census was 51.

The facility had a specific needs contract, dated 10/08/24, with ten residents serviced by the contract.

The specific needs contract indicated:

·Day shift, 6:00 am-2:00pm, three caregivers and one med tech.

·Swing shift, 2:00pm-10:30pm, three caregivers and one med tech.

·Night shift, 10:00pm-6:30pm, two caregiver and one med tech.

The facility ' s posted staffing plan indicated:

·Day shift, 6:00 am-2:00pm, three caregivers and two med techs.

·Swing shift, 2:00pm-10:30pm, two caregivers and one med tech.

·Night shift, 10:00pm-6:30pm, two caregivers and one med tech.

The facility ' s posted staffing plan failed to account for the staffing requirements of the specific needs contract.

The facility ' s master staff schedule indicated:

·" SN "  for staff members responsible for specific needs residents and  " ALF "  for staff members responsible for all other residents;

·The facility scheduled one caregiver and one med tech on night shift, delineated as  " SN; "  and

·One direct care staff delineated as  " ALF. "

On 01/29/25, Staff 11 (Caregiver) stated s/he was  " not sure "  what the difference was between  " SN "  and  " ALF "  on the schedule and management had never told care staff.

The facility had one resident who required two-person transfer assistance and was not on a specific needs contract. The facility would be unable to provide assistance during an evacuation with only one direct care staff assigned to non-specific needs residents.

A review of the facility ' s schedule for night shift, dated 01/19/25 through 01/31/25 revealed the facility was not staffing to meet the combined needs of residents serviced by the specific needs contract or the assisted living residents.  

It was determined the facility did not fully implement and update an acuity-based staffing tool.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4 (Wellness Director, LPN), and Staff 5 (Resident Care Coordinator) on 01/31/25.

Based on observation, interview, and record review, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility ' s failure to provide pre-service fire safety and emergency procedure training to employees was substantiated for 3 of 3 sampled direct care staff (#s 12, 24, and 25). Findings include, but are not limited to:

The facility ' s staff roster indicated:

·Staff 12 ' s (Med Tech) hire date was 11/13/24;

·Staff 24 ' s (Med Tech) hire date was 11/26/24; and

·Staff 25 ' s (Med Tech) hire date was 12/27/24.

The facility ' s pre-service training documentation failed to indicate Staff 12, 24, and 25 had completed required pre-service fire and life safety training.

The facility staff schedule, dated 01/19/25 through 01/31/25, indicated Staff 8, 12, 24, and 25 were scheduled to provide care to residents.

Staff 12 was observed providing care to residents during the site visit.

On 01/28/25, Staff 5 (Resident Care Coordinator) stated  " we don ' t have individual training [records] for everyone. "

The facility ' s failure to provide pre-service fire safety and emergency procedure training to employees was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4 (Wellness Director, LPN), and Staff 5 on 01/31/25.

Based on observation and interview, conducted during a site visit on 01/28/25, 01/29/25, and 01/31/25, the facility's failure to ensure the interior of the facility must be free from unpleasant odors was substantiated. Findings include, but are not limited to:

On 01/28/25, 01/29/25, and 01/31/25 facility hallways were observed to smell strongly of cigarette smoke and bodily odors.

On 01/29/25, Staff 4 (Wellness Director, LPN), stated the hallways smelled of cigarette smoke and bodily odors.

The facility's failure to ensure the interior of the facility must be free from unpleasant odors was substantiated.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Chief Operations Officer), Staff 2 (Regional Clinical Director, RN), Staff 3 (Executive Director), Staff 4, and Staff 5 (Resident Care Coordinator) on 01/31/25.

Verbal plan of correction: Facility to initiate housekeeping refusal logs. Executive Director will be responsible for weekly review of housekeeping logs. The facility will implement plans for residents with a pattern of refusal and enact behavioral support systems if necessary. Care staff will be directed to notify management of unpleasant odors. If cigarette smoke is recognized, facility will intervene immediately.