Print Inspection: L5MV

Based on interview and record review, conducted during a site visit 02/13/24 and 02/14/24, it was confirmed the facility failed to document required elements of an investigation for all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse for 2 of 2 sampled residents (#s 2 and 4). Findings include, but are not limited to:

Resident 4 no longer resides in the facility was unable to be interviewed or observed.

A review of an incident report/investigation, dated 07/28/23, revealed an incident in which Resident 2 was found screaming in Resident 4's bathroom. A progress note dated 07/29/23 revealed Resident 2 had an abrasion to his/her shin. There was no evidence the investigation included follow-up steps or administrator review.

A Temporary Service Plan for Resident 4 dated 02/28/23, stated "Aggression and behaviors toward resident. Monitor and report to MT signs of aggression".

A review of Resident 4's progress notes revealed the following incidents occurred after the 07/28/23 incident of suspected abuse:

*07/29/23: 10:02 pm Resident was making fun of a resident;

*07/31/23: Resident 4 was going up to other residents and calling them "Jews" which was upsetting to other residents;

*08/01/23: Resident 4  was "provoking" residents and "calling them out of name";

*08/02/23: MT heard a scream and Resident 4 was found sitting next to another resident and had pushed another resident to the floor;

*08/05/23: Resident 4 was making "inappropriate" comments to staff and his/her roommate;

*08/17/23: Resident 4 was observed pushing a female resident;

*08/20/23: Resident 4 was "insulting" another resident;

*08/23/23: Resident 4 kicked and tripped a staff member; and

*08/23/23 Resident 4 shoved a table at a resident.

There was no documented evidence the facility implemented interventions for Resident 4's aggressive behaviors.

During an interview on 02/14/23, Staff 1 (Executive Director) stated the facility did not implement interventions, just monitoring and reporting, for Resident 4's aggressive behaviors.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 6 (Director of Operations), and Staff 7 (Resident Care Coordinator) on 02/14/24.

It was confirmed the facility failed to document required elements of an investigation for all reports of abuse and suspected abuse and take measures necessary to protect residents.

Verbal plan of correction: Compliance Specialist (CS) provided ODHS Abuse Reporting and Investigation guide. RCC completed Administrator class and has had recent training in root cause analysis and investigations. Technical Assistance provided by CS in thorough review of elements to be added to an investigation. Will begin including new interventions as well as comprehensive investigation with next incident. Facility will begin conducting daily clinical and care meeting effective 2/15/24.

Based on interview and record review, conducted during a site visit on 02/13/24 and 02/14/24, it was confirmed the facility failed to develop and implement a service plan that was reflective of resident needs for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:

During an interview on 02/13/24, Staff 1 (Executive Director) stated Resident 3 had exhibited sexually aggressive behaviors with another resident, but that resident had since moved out of the facility. S/he also stated that Resident 3 had been physically and verbally combative with staff and attempted to grab a female staff member by the neck. S/he stated the interventions the facility attempted for Resident 3's behaviors were to monitor and provide frequent checks.

An incident report, dated 10/29/23, indicated Resident 3 was found in a female resident's room near the female resident's bed.

A review of Resident 3's Temporary Service Plans indicated the following:

*02/11/24: "No female staff alone in residents room";

*11/04/23: "Make sure to be completing 15 minute checklist on resident. Getting more aggressive with staff. Keep away from female resident"; and

*10/31/23: "Resident is to have 100% eyes on, and to be frequently checked on."

Resident 3's service plan, dated 01/18/24, did not include information regarding his/her aggressive behaviors with staff or residents, or interventions for staff to implement in the event Resident 3 became aggressive.

A review of facility documentation for Resident 3's "15 minute safety checks" were incomplete and frequently un-dated.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 6 (Director of Operations) and Staff 7 (Resident Care Coordinator) on 02/14/24.

The facility failed to develop and implement a service plan that was reflective of resident needs

Verbal plan of correction: Facility to update Resident 3's service plan by 02/16/24 with interventions. Facility to audit other service plans within 30 days for accuracy and completion.

Based on observation and interview, conducted during a site visit on 02/13/24 and 02/14/24, it was confirmed the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. Findings include, but are not limited to:

At approximately 5:15 am on 02/13/24, dirty laundry, including what appeared to be soiled incontinence products, was observed on the floor outside of the facility soiled utility room, with a rack of clean laundry hanging above it. The soiled utility room was disorganized, with clean and folded laundry sitting on the counter directly across from the hopper (a facility used for removing feces from clothing and linens). Washing machines were in the room adjacent to the soiled utility room and there was a door on each side of the laundry room, though the door to the washing machine side was blocked by the rack of clean clothing outside.

During an interview on 02/13/24, Staff 5 (Housekeeper) stated that s/he arrives before laundry staff and will try to help with laundry if s/he is able. S/he further stated they kept clean laundry folded on the counter across from the hopper. S/he acknowledged there are separate entrances/exits, but s/he stated the facility did not use a clean/dirty side.

On 02/14/24 clean laundry was again observed folded on the counter in the soiled utility room a couple feet from the hopper.

During an interview on 02/14/24, Staff 9 (Laundry assistant) stated s/he was working on a plan to separate clean from dirty but didn't have one yet because there was no counter on the clean side to fold laundry.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 6 (Director of Operations) and Staff 7 (Resident Care Coordinator) on 02/14/24.

It was determined the facility failed to establish and maintain infection prevention and control protocols.

Verbal plan of correction: Facility provided a written plan of correction via email on 2/15/24 to address infection control issue identified in their soiled utility room.

Based on observation, interview and record review, conducted during a site visit on 02/13/24 and 02/14/24, it was confirmed the facility failed to to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 1 of 1 sampled resident (#6). Findings include, but are not limited to:

Compliance Specialists (CSs) entered the facility at 5:05 AM on 02/13/24. Staff 2 (MT) answered the door to allow the CSs entrance to the facility and his/her eyes were closed, red and seemed to have just woken up. When the Compliance Specialist stated they looked like they had been sleeping, Staff 2 replied, "Trying to stay awake."

During staff interviews and observations, it was revealed the call light system was not working.

During an interview on 02/13/24, Staff 1 (Executive Director) stated staff should be checking on residents every 15-30 minutes depending on their needs while the call system wasn't working.

During an observation on 02/14/24, an unsampled resident who required 30 minute checks, based upon care needs posted on a clipboard on the hallway, was not checked on for over an hour.

During an interview on 02/14/24, Staff 1 (Executive Director) stated the facility's goal was to respond to call lights within 3 minutes, but up to 10 minutes was acceptable.

A review of the facility's call light records, provided via email on 02/15/23, for 02/14/23-02/15/23, revealed at least seven incidences in which a resident waited longer than 10 minutes for their call light to be answered. Two of those seven were longer than an hour.

During an interview on 02/14/24, Resident 6 stated S/he had to wait a long time for help sometimes, and that his/her roommate had to find someone to help sometimes.

A review of the call light logs received on 02/15/25 revealed Resident 6 waited over 16 minutes for assistance on 02/15/25. Previous call light logs were not able to be accessed because the system was down.

The findings were reviewed with and acknowledged by Staff 1 by phone on 02/15/25.

Verbal plan of correction: ED to audit call light times on a weekly basis to identify trends when call light wait times are the longest and follow-up with staff accordingly. Facility will adjust staffing where needed and provide in-service  to staff on 12/16/24 about call light response times, facility expectations and who to notify if call light times are outside of facility expectation of 10 minute response time, though their goal was 3 minutes.

Based on interview and record review, conducted during a site visit on 02/13/24 and 02/14/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST) for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

Residents 1, 2 and 3's ABST profiles had not been updated in the last quarter.

Interviews with staff, and review of the residents' records noted ABST entries were not reflective of the resident's current care needs in the following areas:

Resident 2:

*Personal hygiene such as shaving and mouth care.

Resident 3:

*Communication, assistive devices for hearing, vision and speech;

*Monitoring behaviors; and

*Cueing or redirecting due to cognitive impairment.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 6 (Director of Operations), and Staff 7 (Resident Care Coordinator) on 02/14/24.

It was determined the facility failed to fully implement and update an Acuity Based Staffing Tool.

Based on observation, interview, and record review it was confirmed the facility failed to keep in good repair all interior materials and surfaces. Findings inlcude, but are not limited to:

On 02/13/24, a hole in the wall was observed in room 11 with exposed wires.

During an interview on 02/14/24, Staff 1 (Executive Director) stated the facility was in the process of repairing and upgrading many items.

In an email received on 02/15/24, Staff 1 included a maintenance list, including the exposed wires in Room 11, which were noted in red, and stated those would be addressed first.

The findings were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 6 (Director of Operations) and Staff 7 (Resident Care Coordinator) on 02/14/24.

It was confirmed the facility failed to keep in good repair all interior materials and surfaces.

Verbal plan of correction: Executive Director and Maintenance Director toured facility on 02/15/24 and identified immediate priorities and provided the list via email.