Print Inspection: YRZR

Based on observation, interview, and record review, conducted during a site visit on 09/28/23, it was determined the facility is not honoring resident choices for food options for sampled resident (#4) as well as unsampled residents. Findings include but are not limited to:

Compliance specialist (CS) observed lunch service on 08/20/24 and determined the facility was serving what was listed on the menu and also had the anytime menu available. Resident were served in the dining room and staff were delivering trays to rooms.

In an interview on 08/20/24, Resident 4 stated the facility provides 3 meals per day. S/he also stated they eat lunch and dinner in the dining room and complained about meat being tough, vegetables being over or under cooked and serving too much broccoli, and would like to see casserole options added to the menu. Resident 4 stated s/he would be attending the "Food Community Meeting" on Tuesday to express concerns.

On 08/20/24 CS (Compliance Specialist) spoke with several unsampled residents in the dining area and residents stated that there are only a couple of good food days per week. The residents seemed to like the sandwich and hamburger options, as well as the soup and salad bar. The residents each stated that they would be attending the food community meeting and expressing their concerns. One resident stated that they serve the same food over and over again.

On 08/20/24 in an interview with Staff 5 (Receptionist) s/he stated that Residents always talk to them regarding the food and that it is always mixed reviews. Menu's are updated and posted weekly as well as alternative menu choices. Staff 5 stated that the Residents have been complimenting the daily soup choices as well as the addition of the salad bar.

CS observed the food service on 08/20/24 with the menu being turkey & gravy or pork roast, yams, with mixed vegetables, most of the residents were eating sandwiches or burgers and soup with the salad bar. CS noticed wilted and slimy lettuce in both of the salad bar bins and had kitchen staff remove the lettuce immediately.  

The above information was shared with Staff 1 (Administrator) on 08/20/24 S/he acknowledged the findings.

It was determined the facility is not honoring resident choices and food preferences.

Plan of Correction: Monthly "Food Community Meetings" for Residents to express concerns and ideas regarding the food choices.

Based on observation, interview, and record review, conducted during a site visit on 08/24/24 it was determined the facility did not provide adequate household services

Based on observation, interview, and record review, conducted during a site visit on 08/20/24 it was determined the facility did not provide household services essential for the health and comfort of the resident that are based upon the resident's needs and preferences. Findings include, but are not limited to:

In an interview on 08/20/24 Staff 1 (administrator) stated a housekeeper had just been hired and that orientation was 08/20/24.   

On 08/20/24 CS (Compliance Specialist) was not able to review a housekeeping schedule for the facility.

At 10:40 am on 08/20/24 several unsampled residents rooms were observed. Some rooms were tidy, with clean restrooms, other rooms had dirty floors, debris on floors, dirty dishes, dirty restrooms etc. and room 143 had feces on the floor, which initiated an immediate response from environmental services. CS also observed dried up leaves at the front entrance of the facility at the first set of doors.

In an interview on 08/20/24, Staff 3 (Caregiver) stated s/he does tidy up rooms and empty trash while performing other care giving duties, and stated that a housekeeper was just hired full-time.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Administrator) on 08/20/24.

Plan of Correction: Housekeeper was just hired.

Based on observation, interview, and record review, conducted during a site visit on 08/20/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool. Findings include, but are not limited to:  

On 08/20/24, three caregivers and two med tech's were observed working the day shift. CS was unable to determine what the posted staffing plan was as it was not posted (but later provided)and Staff 1 (Administrator) had only been on the job for 2 days and was unsure of the posted staffing plan.   

In an interview on 08/20/24 at 10:20 am, Staff 1 (Administrator) stated s/he had started her position a couple of days ago and had not had a chance to access ABST. Staff 1 stated that the facility was going to be moving to a company based tool to create a 24-hour staffing plan. Staff 1 stated the facility was actively hiring and that 3 new caregivers had just been hired. Staff 1 printed off a resident list which included independent living as well as assisted living and there were 51 residents listed for the assisted living side of the facility.

Staff 1 stated s/he was just getting familiar with schedules, staff members and residents.

The above information was shared with Staff 1 on 08/20/24. S/he acknowledged the findings.

It was confirmed the facility had failed fully implement an Acuity Based Staffing Tool.

Plan of Correction: To Be Determined.