Based on observation, interview, and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to provide service plans reflective of resident needs for 2 of 2 sampled residents (#s 21 and 22). Findings include, but are not limited to:

On 06/25/24 and 06/26/24, Residents 21 and 22 were observed being fed lunch by staff members. Resident 21's meal was not observed to be mechanical soft.

Resident 21's service plan, dated 05/21/24, indicated: "Resident will receive diet consistency as ordered of chopped meats" and "receive diet as ordered of mechanical soft."

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated Resident 21's service plan had been updated in February 2024 to include a "mechanical soft" requirement, although there were no physician orders to support the change.

There was no documented evidence Resident 21 had physician orders for a mechanical soft diet.

Resident 22's service plan, dated 04/30/24, showed no indication Resident 22 was in need of feeding assistance.

During an interview on 06/17/24, Staff 17 (Caregiver) stated Resident 22 "sometimes" required feeding assistance.

During an interview on 06/26/24, Staff 10 (Caregiver) stated staff responsible for creating and updating service plans did not ask floor staff for input or recommendations.

It was determined the facility failed to provide service plans reflective of resident needs.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: Completed review of all service plans, completed last month, updated last month. Facility to continue to update service plans as resident's needs change.

Based on observation, interview, and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to implement services for 1 of 1 sampled resident (# 8). Findings include, but are not limited to:

Resident 8's service plan, dated 05/13/24, indicated s/he was to receive "total assistance with eating," assistance washing hands, as well as "total assistance with bathing" twice a week.

On 06/25/24, staff were observed assisting Resident 8 to the dining room table for lunch and bringing food for Resident 8. No staff members were observed assisting Resident 8 with handwashing nor eating. Resident 8 was observed to be spilling food and having difficulties feeding his/herself.

On 06/25/24, Staff 10 (Caregiver) stated the facility used a shower schedule and shower logs to keep track of resident showers.

The facility's shower schedule indicated Resident 8 was to receive showers on Tuesdays and Fridays.

Facility shower logs for Resident 8, dated 04/22/24 through 06/17/24, indicated s/he had received seven showers, roughly one a week. There was no documented evidence Resident 8 had received a shower between 05/17/24 and 06/13/24.

It was determined the facility failed to implement services for a resident.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: Manager on duty was to begin performing rounds to assure resident's hands were washed and audit ADLs after showers. Dining manager will ensure residents are assisting residents with feeding. Daily stand-up meetings will review who changing needs for feeding assistance.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to implement a service plan that reflects the resident's needs for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

Resident 8's service plan, dated 05.13.24, indicated "[Resident 8] does not like male caregivers to help."

During an interview on 06/26/24, Staff 17 (Caregiver) stated Resident 8 preferred female care staff but was "not sure" if it was in his/her care plan.

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated Resident 8 was to receive "female only" care, and there had been a day when a male caregiver was training and provided care to Resident 8.

It was determined the facility failed to implement a resident's service plan.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: There had been no further incidences of male caregivers attending to the Resident. There were no males scheduled to care for residents with female only preference, staff had been trained.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to determine and document an action or intervention needed for a change of condition for 1 of 1 sampled resident (# 6). Findings include, but are not limited to:

Physician orders, dated 02/22/24, indicated staff were to apply Nystatin powder (for skin irritation) twice daily as needed.

During an interview om 06/26/24, Witness 1 (Family Member) stated s/he had discovered an ointment instead of a powder applied to Resident 6's rash.

Progress notes for Resident 6, dated 05/03/24, indicated Staff 2 (Health Services Director, RN) had been notified of a rash on Resident 6 and instructed a med tech to apply the nystatin, and added skin checks to Resident 6 ' s MAR.

Resident 6's service plan, dated 04//02/24, did not indicate regular skin checks were necessary for Resident 6.

There was no documented evidence skin checks had been performed on Resident 6 prior to 05/03/24.

Resident 6's MAR, dated 05/01/24 through 05/31/24, indicated his/her Nystatin powder had not been applied until 05/04/24 at approximately 8:00 pm.

It was determined the facility failed to determine and document an action or intervention needed for a change of condition.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: Facility to immediately begin reviewing skin logs and changes of condition daily at stand-up meeting. Responsibility will fall on Health Services Director until Resident Care Coordinator has been appropriately trained. Next all-staff meeting staff were to be retrained on skin log completion.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 6 of 6 sampled residents (#s 2, 14, 15, 16, 17, and 18). Findings include, but are not limited to:

Physician orders for Resident 2 indicated the following:

·As of 03/22/22 s/he was to receive Risperidone 0.25mg (mood regulation) daily at 8:00 am, 12:00 pm, and 5:00 pm;

·As of 07/01/22, s/he was to receive Fiber Supplement Powder (supplement) daily at 8:00 am; and

·As of 11/08/22, s/he was to receive Polyethylene Glycol 17mg (constipation) daily at 8:00 am.

Resident 2's MAR, dated 06/01/24 through 06/25/24, indicated s/he had not been administered his/her morning doses of Risperidone 0.25mg, Fiber Supplement Powder, or Polyethylene Glycol on 06/16/24.

An incident report, dated 06/17/24, indicated Resident 2 had "missed [his/her] fiber supplement, Miralax, and 2 doses of Risperidone. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24."

Physician orders for Resident 14 indicated the following:

·As of 10/17/23, Resident 14 was to receive Acetaminophen 500mg (pain management), two tabs three times a day;

·As of 11/15/23, Resident 14 was to receive Aspercreme with Aloe (pain management) three times a day;

·As of 07/31/23, Resident 14 was to receive Aspirin EC 81mg (cardiovascular health) once a day;

·As of 11/01/23, Resident 14 was to receive D-Mannose with Cranberry 500-200 (supplement) three times a day;

·As of 07/31/23, Resident 14 was to receive Fiber-lax 625mg (constipation) once a day;

·As of 07/31/23, Resident 14 was to receive Memantine HCL 10mg (dementia) twice a day;

·As of 08/09/23, Resident 14 was to receive Super Papaya Enzyme Plus (supplement) three times a day; and

·As of 07/31/23, Resident 14 was to receive Vitamin D3 50mcg (osteoporosis) once a day.

Resident 14's MAR, dated 06/01/24 through 06/25/24, indicated s/he had not been administered his/her 8:00 am doses of the above prescribed medications on 06/16/24.

An incident report, dated 06/18/24, indicated Resident 14 "missed [his/her] Acetaminophen, Aspercreme, Aspirin, D-mannose cranberry, Fiber-lax caps, Memantine, Miralax, Super papaya enzyme plus, and Vitamin D3 soft gel. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24."

Physician orders for Resident 15 indicated s/he was to receive Acetaminophen 325mg (pain management) two tablets three times daily beginning on 04/09/22, as well as Ensure/Health Shake (weight management) three times a day beginning 04/12/23.

There was no documented evidence on Resident 15's MAR, dated 06/01/24 through 06/25/24, that s/he had received his/her first dose of Acetaminophen of Ensure on 06/17/24.

An incident report, dated 06/16/24, indicated "on 06/17/24, [Resident 15] missed [his/her] Acetaminophen and Ensure. Agency Med Tech did not document passing the medications ... Medications were in the cart upon investigation the afternoon of 06/18/24."

Physician orders for Resident 16 indicated the following:

·As of 06/06/24, Resident 16 was to receive two tablets of Acetaminophen 325mg (pain management) three times a day;

·As of 04/18/22, Resident 16 was to receive Ammens Medicated 5% powder (skin irritation) once a day;

·As of 05/19/24, Resident 16 was to receive Miconazole 2% powder (skin integrity) once a day;

·As of 01/24/23, Resident 16 was to receive 17g of Polyethylene Glycol 3350 (constipation) once daily

·As of 10/26/22, Resident 16 was to receive Sodium Fluoride 1.1% gel (gum health) twice a day; and

·As of 07/07/23, Resident 16 was to receive Risperidone 0.25mg (mood stabilizer) three times a day.

Resident 16's MAR, dated 06/01/24 through 06/25/24, indicated Resident 16 had not been administered the above medications on 06/16/24 on at least one instance.

An incident report, dated 06/17/24, indicated  " On 06/16/24, [Resident 16] missed [his/her] Ammens medicated powder, Miconazole powder, Miralax, Sodium fluoride gel, and risperidone. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24."

During an interview on 06/27/24, Staff 2 stated an agency med tech had not asked staff where resident ' s medication was when passing medication on 06/16/24, and the agency med tech on 06/17/24 had not passed medication to residents. These issues affected multiple residents including Residents 2, 14, 15, 16, and 18.

Physician orders for Resident 17, dated 11/04/23, indicated s/he was to receive Terazosin 2mg (blood pressure) daily at 8:00pm.

Resident 17's MAR, dated 06/01/24 through 06/25/24, indicated s/he did not receive Terazosin 2mg from 06/11/24 through 06/16/24.

An incident report, dated 06/17/24, indicated Resident 17 had missed "6 doses of Terazosin 2mg on 06/11/24, 06/12/24, 06/13/24, 06/14/24, 06/15/24, 06/16/24 at 8 pm."

During an interview on 06/27/24, Staff 2 stated Resident 17's insurance had denied a refill and the pharmacy had not notified the facility.

Resident 18's physician orders, indicated s/he was to receive a Boost Plus Lower Calorie (weight management) twice daily beginning on 12/01/22, as well as Polyethylene Glycol (constipation) 17mg once a day at 8:00 am.

Resident 18's MAR, dated 06/01/24 through 06/25/24, failed to indicate whether s/he had received his/her Boost and Polyethylene Glycol.

An incident report, dated 06/18/24, indicated Resident 18 did not receive his/her Miralax and Boost on 06/17/24, an agency med tech had not recorded the medications, and the medications had been found in the medication cart on 06/18/24.

It was determined the facility failed to carry out medication and treatment orders as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: The facility self-reported the medication errors. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to ensure medications administered by the facility were set-up or poured and documented by the same person who administers the medications for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated an agency staff did not have a log-in to the facility's electronic MAR system and had used a facility med tech's initials to sign resident's MARs on the morning of 06/16/24 for all residents in the 100 and 200 halls of the facility.

An incident report, dated 06/17/24, indicated Resident 2 had "missed [his/her] fiber supplement, Miralax, and 2 doses of Risperidone. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24."

Resident 2's MAR, dated 06/16/24, was signed with the initials of a facility staff member.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: facility implemented agency orientation check sheet prior to working the floor, and check-ins with med techs for assignments. Agency logins were being provided upon arrival.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 6 of 6 sampled residents (#s 2, 14, 15, 16, 17, and 18). Findings include, but are not limited to:

Physician orders for Resident 2 indicated the following:

·As of 03/22/22 s/he was to receive Risperidone 0.25mg (mood regulation) daily at 8:00 am, 12:00 pm, and 5:00 pm;

·As of 07/01/22, s/he was to receive Fiber Supplement Powder (supplement) daily at 8:00 am; and

·As of 11/08/22, s/he was to receive Polyethylene Glycol 17mg (constipation) daily at 8:00 am.

Resident 2's MAR, dated 06/01/24 through 06/25/24, indicated s/he had not been administered his/her morning doses of Risperidone 0.25mg, Fiber Supplement Powder, or Polyethylene Glycol on 06/16/24.

An incident report, dated 06/17/24, indicated Resident 2 had "missed [his/her] fiber supplement, Miralax, and 2 doses of Risperidone. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24."

Physician orders for Resident 14 indicated the following:

·As of 10/17/23, Resident 14 was to receive Acetaminophen 500mg (pain management), two tabs three times a day;

·As of 11/15/23, Resident 14 was to receive Aspercreme with Aloe (pain management) three times a day;

·As of 07/31/23, Resident 14 was to receive Aspirin EC 81mg (cardiovascular health) once a day;

·As of 11/01/23, Resident 14 was to receive D-Mannose with Cranberry 500-200 (supplement) three times a day;

·As of 07/31/23, Resident 14 was to receive Fiber-lax 625mg (constipation) once a day;

·As of 07/31/23, Resident 14 was to receive Memantine HCL 10mg (dementia) twice a day;

·As of 08/09/23, Resident 14 was to receive Super Papaya Enzyme Plus (supplement) three times a day; and

·As of 07/31/23, Resident 14 was to receive Vitamin D3 50mcg (osteoporosis) once a day.

Resident 14's MAR, dated 06/01/24 through 06/25/24, indicated s/he had not been administered his/her 8:00 am doses of the above prescribed medications on 06/16/24.

An incident report, dated 06/18/24, indicated Resident 14 "missed [his/her] Acetaminophen, Aspercreme, Aspirin, D-mannose cranberry, Fiber-lax caps, Memantine, Miralax, Super papaya enzyme plus, and Vitamin D3 soft gel. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24."

Physician orders for Resident 15 indicated s/he was to receive Acetaminophen 325mg (pain management) two tablets three times daily beginning on 04/09/22, as well as Ensure/Health Shake (weight management) three times a day beginning 04/12/23.

There was no documented evidence on Resident 15's MAR, dated 06/01/24 through 06/25/24, that s/he had received his/her first dose of Acetaminophen of Ensure on 06/17/24.

An incident report, dated 06/16/24, indicated "on 06/17/24, [Resident 15] missed [his/her] Acetaminophen and Ensure. Agency Med Tech did not document passing the medications ... Medications were in the cart upon investigation the afternoon of 06/18/24."

Physician orders for Resident 16 indicated the following:

·As of 06/06/24, Resident 16 was to receive two tablets of Acetaminophen 325mg (pain management) three times a day;

·As of 04/18/22, Resident 16 was to receive Ammens Medicated 5% powder (skin irritation) once a day;

·As of 05/19/24, Resident 16 was to receive Miconazole 2% powder (skin integrity) once a day;

·As of 01/24/23, Resident 16 was to receive 17g of Polyethylene Glycol 3350 (constipation) once daily

·As of 10/26/22, Resident 16 was to receive Sodium Fluoride 1.1% gel (gum health) twice a day; and

·As of 07/07/23, Resident 16 was to receive Risperidone 0.25mg (mood stabilizer) three times a day.

Resident 16's MAR, dated 06/01/24 through 06/25/24, indicated Resident 16 had not been administered the above medications on 06/16/24 on at least one instance.

An incident report, dated 06/17/24, indicated  " On 06/16/24, [Resident 16] missed [his/her] Ammens medicated powder, Miconazole powder, Miralax, Sodium fluoride gel, and risperidone. Agency med tech stated [s/he] could not find the medications. All meds were in the cart upon investigation 06/17/24."

During an interview on 06/27/24, Staff 2 stated an agency med tech had not asked staff where resident ' s medication was when passing medication on 06/16/24, and the agency med tech on 06/17/24 had not passed medication to residents. These issues affected multiple residents including Residents 2, 14, 15, 16, and 18.

Physician orders for Resident 17, dated 11/04/23, indicated s/he was to receive Terazosin 2mg (blood pressure) daily at 8:00pm.

Resident 17's MAR, dated 06/01/24 through 06/25/24, indicated s/he did not receive Terazosin 2mg from 06/11/24 through 06/16/24.

An incident report, dated 06/17/24, indicated Resident 17 had missed "6 doses of Terazosin 2mg on 06/11/24, 06/12/24, 06/13/24, 06/14/24, 06/15/24, 06/16/24 at 8 pm."

During an interview on 06/27/24, Staff 2 stated Resident 17's insurance had denied a refill and the pharmacy had not notified the facility.

Resident 18's physician orders, indicated s/he was to receive a Boost Plus Lower Calorie (weight management) twice daily beginning on 12/01/22, as well as Polyethylene Glycol (constipation) 17mg once a day at 8:00 am.

Resident 18's MAR, dated 06/01/24 through 06/25/24, failed to indicate whether s/he had received his/her Boost and Polyethylene Glycol.

An incident report, dated 06/18/24, indicated Resident 18 did not receive his/her Miralax and Boost on 06/17/24, an agency med tech had not recorded the medications, and the medications had been found in the medication cart on 06/18/24.

It was determined the facility failed to carry out medication and treatment orders as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: The facility self-reported the medication errors. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 19). Findings include, but are not limited to:

An incident report, dated 06/12/24, indicated a med tech had processed a physician order incorrectly and administered medication to Resident 19 that was not his/hers.

Resident 19's MAR, dated 06/01/24 through 06/25/24, indicated Resident 19 had received one dose of Cephalexin 500mg (antibiotic) on 06/12/24.

There was no documented evidence of a physician order for Cephalexin 500mg for Resident 19.

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated Resident 19 had been administered a medication prescribed to someone who had never lived at the facility. S/He further stated the "pharmacy put it in wrong [and] we approved wrong."

It was determined the facility failed to carry out medication orders as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: The facility self-reported the medication error. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 4). Findings include, but are not limited to:

An incident report, dated 05/29/24, indicated "Resident [4] missed 88 doses of Atorvastatin [cholesterol medication] 40mg daily at 8pm. The order was hand-written on the quarterly signed physician orders and staff missed putting it in the MAR. No staff initials or documentation is found to indicate who received the orders."

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) confirmed a quarterly review of Resident 4's physician orders in February contained a handwritten order for Atorvastatin 40mg.

A physician order for Resident 14, dated 05/23/24, indicated Resident 14 was to begin Atorvastatin 40mg. The facility was unable to provide a copy of the handwritten physician orders from February.

Resident 14's MARs for 02/2024, 03/2024, and 04/2024, did not include Atorvastatin for Resident 4. Resident 14's MAR, dated 05/01/24 through 05/31/24, indicated s/he had received Atorvastatin 40mg beginning on 05/28/24.

It was determined the facility failed to carry out medication orders as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: The facility self-reported the medication error. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:

Physician orders for Resident 3, dated 04/17/24, indicated s/he was to receive Cranberry 250mg capsule (supplement) three times a day with meals.

Resident 3's MAR, dated 04/01/24 through 04/31/24, indicated s/he had only received his/her morning dose of Cranberry 250mg.

An incident report, dated 04/16/24, indicated the order for Cranberry 250mg "was written for 3 times per day but scheduled for once per day. "

During an interview on 06/27/24, Staff 2 (Health and Wellness Director, RN) stated "whoever approved it on our end didn't catch it" and confirmed Resident 3 had been receiving the Cranberry 250mg once a day when s/he should've received it three times a day.

It was determined the facility failed to administer medication as prescribed for Resident 3.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: The facility self-reported the medication error to the local Seniors and People with disabilities office. Staff had been re-educated on the facility's three-check process for processing physician orders. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on observation, interview, and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 8). Findings include, but are not limited to:

A physician order for Resident 8, dated 11/20/23, indicated s/he was to receive Sennosides Oral Tablet 8.6mg (bowel care) on Monday, Wednesday, and Friday. The order was to be discontinued on 05/03/24.

Resident 8's MARs, dated 11/01/23 through 05/31/24, indicated s/he had received Sennosides Oral Tablet 8.6mg daily.

During an interview on 06/26/24, Staff 2 (Health Services Director, RN) stated "we clicked approve without checking it was supposed to be Monday/Wednesday/Friday. "

It was determined the facility failed to carry out medication orders as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings. The medication error had been resolved.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 12). Findings include, but are not limited to:

Physician orders for Resident 12, dated 08/16/23, indicated Resident 12 was to receive Memantine HCL 10mg (for dementia) twice daily at 8:00 am and 6:00 pm.

Resident 12's MAR, dated 05/01/24 through 05/31/24, indicated s/he had not received his/her 8:00 am dose of Memantine on 05/12/24 through 05/14/24, and had not received his/her 6:00 pm dose on 05/12/24 and 05/13/24. Notes indicated "medication not available" and "awaiting delivery."

A medication error report, dated 05/13/24, indicated Resident 12 had missed his/her doses of Memantine beginning on 05/12/4. Notes indicated Resident 12's medication was not reordered timely from the pharmacy.

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated the facility had failed to reorder Resident 12's medication timely.

It was determined the facility failed to carry out medication and treatment orders as prescribed.

Verbal plan of correction: The facility self-reported the medication error. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 13). Findings include, but are not limited to:

Physician orders for Resident 13, dated 01/30/24, indicated Resident 13 was to receive Alpha Lipoic Acid 300mg (supplement) 2 capsules a day at 8:00 am, for a total of 600mg a day.

An incident report, dated 05/11/24, indicated a med tech had been giving Resident 13 two 600mg capsules a day.

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated the pharmacy had originally sent 300mg capsules, and when the pharmacy refilled the prescription with 600mg capsules "no one checked the dose on the bottle," and continued to give Resident 13 two capsules.

It was determined the facility failed to carry out medication and treatment orders as prescribed.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: The facility self-reported the medication error. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

Physician Orders for Resident 2, dated 03/22/22, indicated s/he was to receive Risperidone ODT 0.5mg (emotion regulation) daily at 8:00 am, 12:00 pm, and 7:30 pm.

Resident 2's MAR, dated 03/01/24 through 03/31/24, indicated s/he had not received his/her 12:00 pm dose of Risperidone.

An incident report, dated 04/01/24, indicated Resident 2 had not received his/her mid-day scheduled dose of Risperidone on 03/31/24.

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated Resident 2 had not received his/her medication due to a  " staffing issue. "

It was determined the facility failed to administer medication as prescribed for Resident 1.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: The facility self-reported the medication error to the local Seniors and People with disabilities office. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication orders as prescribed for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

Resident 1's physician orders, dated 02/19/24, indicated s/he was to be administered Acetaminophen 325mg (pain medication) daily at 8:30 am, 1:00 pm, and 7:00 pm.

Resident 1's MAR, dated 03/01/24 through 03/31/24, indicated s/he had not received his/her 1:00 pm dose of Acetaminophen.

An incident report, dated 04/01/24, indicated Resident 1 had not received his/her mid-day scheduled dose of Acetaminophen on 03/31/24.

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) confirmed Resident 1 was to receive Acetaminophen three times a day and stated Resident 1 had received his/her AM dose of Acetaminophen late because there had only been one med tech on duty on 03/31/24. S/he further stated the med tech had been advised by the previous RN to hold the mid-day dose as it would've been too closely administered to the AM dose.

It was determined the facility failed to administer medication as prescribed for Resident 1.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: The facility self-reported the medication error to the local Seniors and People with disabilities office. Staff involved were educated at the time of the incident. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:

Physician orders for Resident 3, dated 04/17/24, indicated s/he was to receive Cranberry 250mg capsule (supplement) three times a day with meals.

Resident 3's MAR, dated 04/01/24 through 04/31/24, indicated s/he had only received his/her morning dose of Cranberry 250mg.

An incident report, dated 04/16/24, indicated the order for Cranberry 250mg "was written for 3 times per day but scheduled for once per day. "

During an interview on 06/27/24, Staff 2 (Health and Wellness Director, RN) stated "whoever approved it on our end didn't catch it" and confirmed Resident 3 had been receiving the Cranberry 250mg once a day when s/he should've received it three times a day.

It was determined the facility failed to administer medication as prescribed for Resident 3.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: The facility self-reported the medication error to the local Seniors and People with disabilities office. Staff had been re-educated on the facility's three-check process for processing physician orders. The facility had begun to implement weekly audits to monitor their medication exception report. The facility had begun to review missed medications during daily clinical meetings.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to keep an accurate Medication Administration Record for 1 of 1 sampled resident (# 17). Findings include, but are not limited to:

Physician Orders for Resident 17, dated 11/04/23, indicated s/he was to receive Terazosin 2mg (blood pressure) once a day.

Resident 17's MAR, dated 06/01/24 through 06/25/24, indicated:

·S/he had not received his/her Terazosin on 06/05/24, 06/08/24, and 06/11/24 through 06/16/24. Notes indicated "medication unavailable;" and

·Terazosin 2mg was marked as administered on 06/06/24, 06/07/24, 06/09/24, and 06/10/24.

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated "I know they didn't have the med here in the building when they marked it."

Physician orders for Resident 17, dated 11/04/23, indicated Resident 17 was to receive Memantine HCL 10mg (Alzheimer ' s medication) twice daily, at 8:00 am and 8:00 pm.

Resident 17's MAR, dated 06/01/24 through 06/25/24, indicated:

·Memantine HCL was not administered to Resident 17 on 06/21/24 at 8:00 am, notes indicated "refused;"

·Memantine HCL was not administered 06/22/24 at 8:00 am, 06/23/24 at 8:00 am or 8:00 pm, nor 06/24/24 at 8:00 am. Notes indicated "medication not available;" and

·Memantine HCL was marked as administered on 06/21/24 and 06/22/24 at 8:00 pm.

In an interview on 06/27/24, Staff 2 stated there were "two documentations in error for Memantine" for the 21st and 22nd.

It was determined the facility failed to keep an accurate Medication Administration Record.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: The facility had begun to implement weekly audits to monitor their medication exception report.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, 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 for 1 of 1 sampled resident (# 8). Findings include, but are not limited to:

During an interview on 06/26/24, Staff 17 (Caregiver) stated "I think needs get behind [when understaffed]" and "showers won't be able to get done."

Resident 8's service plan, dated 05/13/24, indicated s/he was to receive "total assistance with bathing" twice a week.

On 06/25/24, Staff 10 (Caregiver) stated the facility used a shower schedule and shower logs to keep track of resident showers.

The facility's shower schedule indicated Resident 8 was to receive showers on Tuesdays and Fridays.

Facility shower logs for Resident 8, dated 04/22/24 through 06/17/24, indicated s/he had received seven showers, roughly one a week. There was no documented evidence Resident 8 had received a shower between 05/17/24 and 06/13/24.

The facility's posted staffing plan indicated:

·Day shift: Two med techs and eight caregivers;

·Swing shift: Two MT and eight CG; and

·Night shift: One MT and four CG.

The facility's staff schedule, dated 06/04/24 through 06/11/24, indicated the facility did not staff to their posted staffing schedule on four out of seven days.

It was determined the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of a resident.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2 (Health Services Director, RN), Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: Manager on duty was to begin auditing ADLs after showers. Business Office Manager had taken over all staffing issues, the facility to had begun to implement corrective action per policy and increased recruiting efforts. In the event of callouts shifts were offered to staff, and agency staff were being utilized. CGs and MTs had been hired the week of 06/23/24 through 06/28/24.

Based on observation, interview, and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to have enough staff to meet the scheduled and unscheduled needs of 1 of 1 sampled resident (# 6). Findings include, but are not limited to:

The facility's posted staffing plan indicated:

·Day shift (6:00 am to 2:00 pm): 2 med techs and 8 caregivers;

·Swing shift (2:00 pm to 10:00 pm): 2 med techs and 8 caregivers; and

·Night shift (10:00pm to 6:00 am): 1 med tech and 4 caregivers.

The facility was observed to be divided into four separate numbered halls, or "houses:" Lighthouse (100), Mountain (200), River (300), and Flower (400).

In an interview on 06/25/24, Staff 1 (Executive Director) stated there were supposed to be two caregivers for each of the four halls in the facility, as well as two med techs, one responsible for halls 100 and 200 and the other for halls 300 and 400, although the facility tried to staff extra in Flower because it ' s a  " loud hall "  and requires more care.

During an interview on 06/26/24, Staff 17 (Caregiver) stated the facility gets behind on needs, and showers don ' t get done when there are not enough staff. S/He further stated three caregivers was needed in Flower, and  " I don't think two [caregivers on shift was] working every day."

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated there had been medication errors due to "staffing issues." S/He further stated "weekends are super hard, a lot of call-ins"  and the facility was sometimes "scrambling for agency [staff coverage]."

In an interview on 06/26/24, Staff 15 (Caregiver) stated the facility is "sometimes short staffed over the weekend."

At approximately 2:42 pm on 06/25/24, only one caregiver was observed in the 100 hall. Staff 22 (Caregiver) stated s/he was the only caregiver in the hall as s/he was "waiting for someone to show up."

During an interview on 06/27/24, Staff 12 stated "all this week staffing is a mess," and "lately we've been short staffed  ... a lot of call outs."

On 06/27/24 from approximately 2:30pm-3:00pm, the following was observed:

·In Mountain, a caregiver was by his/herself with a resident requiring a two-person assist;

·A caregiver was alone in Flower, where one resident required a two-person assist. The caregiver assigned to the hall stated  " this house is supposed to [have] three [caregivers];

·A caregiver was alone in the Lighthouse hall;

·There were two day-shift caregivers in River, waiting on swing shift staff to arrive; and

·There was one med tech on shift who was waiting on swing shift med techs to arrive.

During an interview on 06/27/24, Staff 1 stated swing shift and agency staff were "on their way."

It was determined the facility failed to have enough staff to meet the scheduled and unscheduled needs of residents.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs for 1 of 1 sampled resident (# 2). Findings include, but are not limited to:

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) stated Resident 2 had not received his/her medication due to a "staffing issue."

The facility's posted staffing plan indicated:

·Day shift: 2 MT and 8 caregivers (CG);

·Swing shift: 2 MT and 8 CG; and

·Night shift: 1 MT and 4 CG.

Facility timecards indicated only one med tech had worked the day shift on 03/31/24.

Physician Orders for Resident 2, dated 03/22/22, indicated s/he was to receive Risperidone ODT 0.5mg (emotion regulation) daily at 8:00 am, 12:00 pm, and 7:30 pm.

Resident 2's MAR, dated 03/01/24 through 03/31/24, indicated s/he had not received his/her 12:00 pm dose of Risperidone.

An incident report, dated 04/01/24, indicated Resident 2 had not received his/her mid-day scheduled dose of Risperidone on 03/31/24 because there had only been one MT on shift.

It was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of Resident 2.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: Business Office Manager had taken over all staffing issues, the facility to had begun to implement corrective action per policy and increased recruiting efforts. In the event of callouts shifts were offered to staff, and agency staff were being utilized. CGs and MTs had been hired the week of 06/23/24 through 06/28/24.

Based on interview and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:

During an interview on 06/27/24, Staff 2 (Health Services Director, RN) confirmed Resident 1 was to receive Acetaminophen (pain medication) three times a day and stated Resident 1 had received his/her AM dose of Acetaminophen late because there had only been one med tech (MT) on duty on 03/31/24. S/he further stated the MT had been advised by the previous RN to hold the mid-day dose as it would ' ve been too closely administered to the AM dose.

The facility's posted staffing plan indicated:

·Day shift: 2 MT and 8 caregivers (CG);

·Swing shift: 2 MT and 8 CG; and

·Night shift: 1 MT and 4 CG.

Facility timecards indicated only one med tech had worked the day shift on 03/31/24.

Resident 1's physician orders, dated 02/19/24, indicated s/he was to be administered Acetaminophen 325mg daily at 8:30 am, 1:00 pm, and 7:00 pm.

Resident 1's MAR, dated 03/01/24 through 03/31/24, indicated s/he had not received his/her 1:00 pm dose of Acetaminophen on 03/31/24.

An incident report, dated 04/01/24, indicated Resident 1 had not received his/her mid-day scheduled dose of Acetaminophen on 03/31/24 because there had only been one MT on shift.

It was determined the facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of Resident 1.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.

Verbal plan of correction: Business Office Manager had taken over all staffing issues, the facility to had begun to implement corrective action per policy and increased recruiting efforts. In the event of callouts shifts were offered to staff, and agency staff were being utilized. CGs and MTs had been hired the week of 06/23/24 through 06/28/24.

Based on observation, interview, and record review, conducted during a site visit on 06/25/24 through 06/28/24, it was confirmed the facility failed to fully implement and update an acuity-based staffing tool (ABST) for 2 of 3 sampled residents (#s 8 and 20). Findings include, but are not limited to:

On 06/26/24, Resident 8 was observed to communicate with staff non-verbally through tapping and gesturing, which took staff time to understand his/her needs.

Resident 8's service plan, dated 05/13/24, indicated s/he "has difficulty communicating and receiving information."

The facility's ABST, reviewed on 06/28/24, failed to include time needed for communication with Resident 8.

On 06/26/24, Resident 20 was observed to have his/her left arm in a sling and was provided transferring and feeding assistance by staff.

A "Change in Plan of Care Communication" form, dated 06/21/24, indicated Resident 20 had suffered a broken clavicle.

A "Change in Plan of Care Communication" form, dated 06/24/24, indicated "[Resident 20] is unable to use [his/her] left arm to "push" off [his/her] chair for transferring, [s/he] may need extra assistance with transferring during this time."

During an interview on 06/27/24, Staff 20 (Caregiver) stated Resident 20 sometimes required transferring and feeding assistance due to his/her recent injury.

The facility's ABST, reviewed on 06/28/24, failed to include time required for feeding assistance or transferring for Resident 20 because of his/her recent change of condition.

During an interview on 06/28/24, Staff 2 (Health Services Director, RN) stated s/he was responsible for updating the facility's ABST, Resident 20 had experienced a recent change of condition, and s/he had not updated the facility's ABST to reflect Resident 20's increased care needs since the change of condition occurred.

It was determined the facility failed to fully implement and update their ABST.

The findings of the investigation were reviewed with and acknowledged by Staff 1 (Executive Director), Staff 2, Staff 3 (Chief Operations Officer), Staff 4 (Vice President), Staff 5 (Regional Health Services Director), Staff 6 (Regional Director of Operations), Staff 7 (Regulatory), Staff 8 (Vice President, Clinical), and Staff 9 (Operations Support) on 06/28/24.