Based on observation, interview and record review, conducted during a site visit on 02/26/24 and 02/28/24, it was confirmed the facility failed to ensure each residential care and assisted living facility must be licensed, maintained, and operated as a separate and distinct facility. Findings include, but are not limited to:
During an interview on 02/26/24, Staff 4 (MT) stated the Memory Care community had to call staff over from the Assisted Living Community to assist residents with behaviors two times per week.
During an interview on 02/26/24, Staff 6 (MT/CG) stated on night shift of 02/17/24, there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community.
During an interview on 02/28/24, Staff 10 (CG) stated on night shift of 02/23/24 there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community.
Time cards for the facility were reviewed for night shift on 02/17/24 and 02/23/24 which confirmed there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community.
Upon entrance to the facility at 12:50 am on 12/28/24, two ALF staff members were observed in the memory care.
During an interview on 02/28/24, Staff 6 (ALF MT) stated ALF staff are pulled to help in the MC at least a couple times/week.
During an interview by phone on 02/28/24, Staff 8 (Executive Director) stated she was not aware staff were being shared between facilities.
The facility failed to ensure each residential care and assisted living facility must be licensed, maintained, and operated as a separate and distinct facility.
The findings were reviewed with and acknowledged by Staff 8 by phone on 03/01/24.
Verbal plan of correction: Administrator will work to get exception to float an additional staff between facilties. Counseling with RCCs to not leave shifts open so that MTs aren ' t working the whole facility on night to be provided by 03/01/24. Administrator will educate staff on communicating their needs and not sharing staff between two facilities.
Based on observation, interview and record review, conducted during a site visit on 02/26/24 and 02/28/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:
A review of the facility's posted staffing plan indicated that one MT and one CG were to be scheduled on night shift.
1 CG and 1 MT were observed working on night shift on 02/26/24 and 02/28/24.
During an interview on 02/26/24, Staff 4 (MT) stated the Memory Care Community (MCC) had to call staff over from the Assisted Living Community (ALF) to assist residents with behaviors in the MCC two times per week. Staff 4 further stated that residents have pulled their fire alarms multiple times, which unlocked three exit doors and the gate from their courtyard. Staff 4 stated that when that happened on noc shift, they were not able to monitor the exits with only two scheduled staff.
Records were requested for each time the fire alarm had been activated in the previous six months, but were not provided by 03/06/24.
During an interview on 02/26/24, Staff 6 (MT/CG) stated on night shift of 02/17/24, there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community.
During an interview on 02/28/24, Staff 10 (CG) stated on night shift of 02/23/24 there was only one MT who was responsible for passing medications for both the Assisted Living and Memory Care Community.
Time cards for the facility were reviewed for night shift on 02/17/24 and 02/23/24 which confirmed there was only one MT who was responsible for passing medications for both the ALF and MCC.
Upon entrance to the facility at 12:50 am on 12/28/24, two ALF staff members were observed in the MCC.
During an interview on 02/28/24, Staff 6 (ALF MT) stated ALF staff awere pulled to help in the MCC at least a couple times per week.
The facility failed to provide 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 8 (Executive Director) by phone on 03/01/24.
Verbal plan of correction: Executive Director is working with her supervisor to have a night shift float and will request an exception from Operations and Policy Analyst for that. Facility will hire a float staff for that once exception is in place. In the mean time, will have RCC or other staff cover an additional night shift.
Based on observation, interview and record review, conducted during a site visit on 02/26/28/24 and 02/28/24, it was confirmed facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing for 1 of 1 sampled staff (#5). Findings include, but are not limited to:
Staff 5 was observed working as a CG in the Memory Care Community (MCC) on 02/26/24.
During an interview on 02/26/24, Staff 5 stated that s/he worked two shifts as a MT in the ALF and two shifts as a CG in the MCC per week since November 2023. S/he further stated that on night shift of 02/17/24, s/he had worked as the only MT for both the ALF and the MCC and had not been trained to pass medications in the MCC.
Time cards for 02/17/24 confirmed Staff 5 had worked as the only MT for both the ALF and the MC.
There was no documented evidence that Staff 5 had received training for the Memory Care.
The facility failed to have a training program that includes methods to determine competency of direct care staff through evaluation, observation, or written testing.
The findings were reviewed with and acknowledged by Staff 8 (Executive Director) by phone on 03/01/24.
Verbal plan of correction: Train staff in question. Audit all training documents to ensure that staff have received training and its documented. Audit will be done by Wednesday and training updated within 30 days.