Based on record review and interview, it was confirmed that the facility failed to implement effective methods to responding to and resolving resident complaints. Findings include but not limited to:
During an unannounced site visit on 1/5/2023, Compliance Specialist (CS) reviewed the facility's grievance binder. The policy on the cover of the binder dated 5/19/2017 stated "All grievances will be follow-up[ed] on and have a plan towards resolution in place within 5 working days from date of notification to the executive director." There were no grievances in the binder from the last four months and several grievances including the first one dated 1/23/22 had no investigation or follow up.
During interview, Staff #1 stated they had not had any complaints in the last few months and they were not tracking grievances.
These findings were reviewed with Staff #1, Staff #10, Staff #12, Staff #15 and Staff #16 on 1/5/2023 who were agreement.
Plan of Correction: Facility to re-implement grievance binder to track concerns and ensure resolutions.
Based on observation, interview, and record review, it was confirmed that the facility failed to have the service plan be readily available to staff. Findings include but not limited to:
During an unannounced site visit on 1/5/2023, Compliance Specialist (CS) reviewed all four of the facility's service planning binders that are available to staff. CS was unable to locate a service plan for Resident #2 (R2). There were two Interim Service Plan updates dated 11/27/22 and 12/13/22 available for R2.
During interview, Staff #10 stated that R2's service plan was updated about a week ago, that R2's care needs had increased but that they were not able to print the service plan at that time because the printers were not working.
CS requested a copy of R2's service plan which was updated on 12/24/2022.
These findings were reviewed with Staff #1, Staff #10, Staff #12, Staff #15, and Staff #16 on 1/5/2023 who were in agreement.
Plan of Correction: Audit of service plan binders to be completed and all missing service plans to be added to binders by end of day on 1/6/2023.
Based on observation, record review and interview, it was confirmed that the facility failed to carry out medication orders as prescribed. Findings include but not limited to:
During an unannounced site visit on 1/5/2023, Compliance Specialist (CS) observed a resident request an as needed pain medication at 10:38am on 1/5/2023. It was administered after 1:00pm.
A review of Resident #9 (R9)'s Medication Administration Record (MAR) for July-August 2022 revealed 12 occasions when a medication was not given due to not being available. A review of Resident #11 (R11) MAR for March 2022 revealed 3 occasions when a medication was not given due to not being available
These findings were reviewed with Staff #1, Staff #10, Staff #12, Staff #15 and Staff #16 on 1/5/2023 who were in agreement.
Plan of Correction: Review of medication administration policies/chain of commands and communication between CGs and Med Techs at all staff on 1/10/23.
Based on record review and interview, it was confirmed that the facility failed to keep an accurate Medication Administration Record (MAR). Findings include but not limited to:
A review of Resident #11 (R11)'s MAR for March 2022 revealed an incident on 3/9/2022 when an employee administered a medication to R11 other than the person who signed off on the MAR.
During interview, Staff #16 (S16) stated it was likely because the assigned Med Tech had not been delegated for this task, so another Med Tech on duty who was delegated gave them medication.
These findings were reviewed with Staff #1, Staff #10, Staff #12, Staff #15 and Staff #16 on 1/5/2023 who were in agreement.
Plan of Correction: Review MAR documentation at all-staff on 1/10/23. New Registered Nurse (RN) starting on 1/9/23 and will take over and confirm all delegations.
Based on observation, interview and record review, it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to:
During an unannounced site visit on 1/5/2023, (CS) observed a resident request an as needed pain medication at 10:38am on 1/5/2023. It was administered after 1:00pm.
During interview Staff #3 (S3) stated that it can take up to two hours to assist individuals with toileting at times.
A review of Resident #9 (R9) ' s July - August 2022 Medication Administration Record and Treatment Administration Record (MAR/TAR) revealed four instances when resident was not given a shower, because "not enough staff " , "not done" and "caregiver didn't have enough time "and two instances when COVID-19 monitoring was not done because "only two med techs no time. "
These findings were reviewed with and acknowledged by Staff #1, Staff #10, Staff #12 Staff #15 and Staff #16 on 1/5/2023 who were in agreement.
Plan of Correction: Facility is currently hiring and actively recruiting staff on indeed and in their community.
Based on record review and interview, the facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned
During an unannounced site visit on 1/5/2023, Compliance Specialist reviewed all staff training documents for Staff #13 (S13) which revealed many Med Tech (MT) and Caregiver skills in which competencies were not verified by observation, evaluation, or written testing.
During interview, Staff #12 (S12) stated that competencies should have been verified by another MT and a nurse, as per their policy. Staff #4 (S4) stated that some caregivers did not know how to close Resident #9 (R9)'s catheter bag which would result in urine spills.
These findings were reviewed with Staff #1, Staff #10, S12 Staff #15 and Staff #16 on 1/5/2023 who were in agreement.
Plan of Correction: Resident Care Coordinators and Registered Nurses to verify training competencies completed for all new-hires. Catheter care in-service to be conducted at all-staff meeting on 1/10/23. Business Office Manager to audit staff training for current employees and verify competencies.
Based on observation, interview and record review, it was confirmed that the facility failed to ensure all interior and exterior materials and surfaces (eg floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of residents must be kept clean and in good repair. Findings include but not limited to:
During an unannounced site visit on 1/5/2023, Compliance Specialist (CS) completed several walk throughs of the facility and observed R3's room which was under construction. There were areas of the carpet throughout the facility that were stained with black matter. CS observed an unrepaired whole in a vacant resident room. An area behind the first floor caregiver station had damaged laminate flooring that was lifting up. CS observed an unrepaired whole in a vacant resident room. Resident #9 (R9's) room had a strong, pervasive odor of urine.
During an interview, Staff #11 (S11) stated that the roof leaks in several places and the facility has obtained bids to replace it. Staff #4 (S4) stated that some caregivers did not know how to close R9's catheter bag which would result in urine spills, that there is a cat in the room with a litter box, and that the resident often spills things resulting in odors and stains.
CS reviewed three separate bids for roof replacement dated 2/10/2020, 12/6/2022 and 8/24/2022.
These findings were reviewed with Staff #1, Staff #10, Staff #12, Staff #15 and Staff #16 on 1/5/2023 who were in agreement
Plan of Correction: Facility has received bids for new roof and has sent to corporate for approval to move forward. All carpet to be shampooed by 1/27/2023.