Based on observation, interview, and record review, conducted during a site visit on 03/05/24 and 03/06/24, it was confirmed the facility failed to post in a routinely accessible and conspicuous location a copy of the most recent re-licensing survey. Findings include but are not limited to:
In an interview on 03/05/24, Staff 1 (Executive Director) stated s/he was hired in October 2023 and was visited by surveyors during that time.
On 03/06/24, the Compliance Specialist (CS) observed the faciltiy's posted survey binder near the front door. Upon review of the required posting, it was noted the available survey findings were dated 02/12/2020.
On, 03/06/24, these findings were reviewed with and acknowledged by Staff 1.
VPOC:
The Excutive Director will update the binder with re-licensing survey and revisit findings will be posted upon receipt of the final reports.
Based on interview and record review, conducted during a site visit on 03/05/24 and 03/06/24, it was confirmed the facility failed to ensure the completeness and accuracy of resident records for 1 of 1 sampled resident (#2) whose records were reviewed. Findings include, but not limited to:
A review of Resident 2's MAR, dated 08/01/23 through 09/12/23, indicated the following:
* Resident 2 had been prescribed "acetaminophone 500mg, take two tablets (1000mg) by mouth three times daily for pain".
* On 08/09/23 at 9:00pm, the MAR did not document if this medication dose was given or not and why.
In an interview on 03/06/24 at 5:30 pm, Staff 1 was shown Resident 2's MAR and confirmed the inaccuracy.
On 03/06/24, these findings were reviewed with and acknowledged by Staff 1 (Executive Director).
It was confirmed the facility failed to ensure the completeness and accuracy of resident records.
Based on observation and interview, conducted during a site visit on 03/05/24 and 03/06/24, it was confirmed the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. Findings include, but are not limited to:
During a walk-through of the facility on 03/05/24 at 10:37 am, the Compliance Specialist (CS) observed the following:
* The facility was a two-story building, built on a hill.
* The main entrance was on the first floor with a lower parking lot.
* The second floor contains the dining room and resident apartments.
* The dining room had two exit doors (Northwest and Northeast) that face the Eastside of the building and leads out into the upper parking lot that was connected to the main entrance.
* The upper parking lot was blocked off due to constructions using caution tape, cones, and a construction vehicle.
* The NW exit door was unlocked, unblocked, available for egress and led into the construction area.
* There were no construction workers onsite.
* The construction area used wood planks to cover holes in the ground with white spray paint on it.
* The sidewalk pathway was blocked by caution tape tied to cones and a wooden bench on its side, which caused pedestrians to walk across the uneven terrain of the concstruction area.
In an interview on 03/05/24 at 11:25 am, Staff 11 stated the following:
* Construction workers were here yesterday.
* The construction workers were here to install a generator.
* The wooden bench was "on all fours" yesterday.
* There has not been any caution tape applied to the NW door.
The area was toured with Staff 11 (Building Services Director) and who acknowledged how the pathway currently blocked, directs residents to ambulate through the construction area's uneven terrain.
On 03/05/24, these findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 11.
Verbal Plan of Correction:
Staff 11 proceeded to place caution tape on the NW door and re-organized the construction area to allow for a pathway for egress.
Based on interview, observation, and record review, conducted during a site visit on 03/05/24 and 03/06/24, it was determined the facility failed to provide three daily meals. Findings include, but not limited to:
In an interview on 03/05/24, Resident 2 stated the following:
* S/He missed meals so often, s/he began tracking services.
* "No lunch was provided on 02/08, 02/14, 02/29...[and] 03/01."
* "I think they forget about me."
* "I think I've told a MT, maybe."
* S/He uses the call cord to get their attention when s/he notices the meal had not been delivered yet.
On 03/05/24, a review of Resident 2's February 2024 calendar used to self-track lapses in services indicated "no lunch" was provided on 02/08/24, 02/14/24, and 02/29/24.
In an interview on 03/05/24, Staff 12 (Dining Director) stated the following:
* There was no dietary board.
* Snacks were available in the public fridge for residents to self serve or for care givers to provide.
* When s/he received doctor orders or resident directed instruction, Staff 12 update a word document to place at the front.
* A Food Council meeting occurred on 02/20/24, but no notes were finalized.
* There was no updated meal tracker.
On 03/05/24 at approximately 1:10pm, the Compliance Specialist observed the kitchen's dietary board to be incomplete. An outdated resident roster, dated 01/19/2024, was posted with resident's marked with "D" or "T" to indicate if the resident receives dining room services or tray service.
On 03/06/24 between 9:25 am and 10:00 am, the Compliance Specialist observed the following:
* Staff 13 (Dining Attendant) delivered breakfast trays to the first floor using a handwritten list of residents' apartment numbers on a paper mat based on the resident roster posted in the kitchen.
* At 9:27am, Unit 113 was delivered their breakfast tray, then proceed to 116.
* Resident 10 asked Staff 13 if Resident 1 got breakfast. Staff 13 replied "[s/he] was at the dining room". At which time, Staff 13 made contact with Resident 1 who stated s/he had not eaten and would like a tray. Staff 13 provided a tray.
* Staff 13 delivered a tray to unit 122. Staff 13 called out to the resident that his/her meal was here but no response. Staff 13 took one step into the apartment to place tray on counter.
* CS observed resident in room 122 to be slumped over in their chair. CS prompted care staff to check on resident and let them know breakfast was delivered.
* Staff 13 ran out of trays for the last three apartments and had to return to the kitchen on the second floor to retrieve additional trays.
In an interview on 03/06/24, Staff 13 stated the following:
* The second floor's meals were delivered first, then the first floor.
* There were two delivery box carts but only one is used for deliveries.
* The delivery boxes were not electric and only holds 20 trays.
* Under the current system, it is possible fo someone not to recieve their meal.
In an interview on 03/06/24, Resident 7 stated s/he missed two meals in the last couple of months and the last time they missed a meal was "one and half weeks ago on a weekend."
It was determined the facility failed to provide three daily meals.
On 03/06/24, these findings were reviewed with and acknowledged by Staff 1 (Executive Director).
Verbal Plan Of Correction:
Effective immediately, Staff 12 will implement an updated resident meal tracker, utilize the second delivery box and vary the direction in which trays are served, and will work with Staff 3 (Wellness Service Director) to obtain all resident's dietary restrictions and update the dietary board for kitchen staff.
Based on observation, interview, and record review, during a site visit on 03/05/24 and 03/06/24, it was confirmed the facility failed to ensure the implementation of services for 1 of 3 sampled residents (#2). Findings include, but are not limited to:
In an interview on 03/05/24 at 3:50pm, Resident 2 stated s/he was not provided lunch on four occasions in the last 30 days and did not get a shower on his/her shower day on Friday, 03/01/24; and on Tuesday, 03/05/24, s/he was offered a shower by an agency staff member but declined because the staff member is of opposite gender.
During Resident 2's interview, at 4:15pm, Staff 14 (MT) entered Resident 2's apartment to provide medication and when Staff 14 was leaving the apartment, s/he overheard Resident 2's statement about his/her shower not getting provided. Staff 14 stated s/he has left notes for staff to ensure a staff member of Resident 2s gender provided the care, then assured Resident 2 that s/he would provide his/her shower.
A review of Resident 2's service plan, dated 12/28/23, and progress notes, dated 03/02/24 through 12/08/23, indicated the following:
* In the area of bathing, faciltiy staff will provide "a moderate degree of assistance.... assistance may include reminding/prompting... setting up shower.... assisting into tub/shower, washing back and/or hair, and cleaning up afterwards...." and "[same gender as resident] only to assist."
*A progress note entered on 03/02/24 at 6:25pm, indicated Resident 2's daughter called to request resident got a shower on Sunday on 03/03/24.
In an interview on 03/06/24 at 10:07am, Resident 2 stated s/he did not get his/her shower on 03/05/24 that Staff 14 said s/he would provide.
A review of the facility's resident shower schedule (undated) and 24-hour communication logs, dated 03/02/24 through 03/06/24, indicated the following:
* Resident 2 was scheduled for showers during swing shift on Tuesday and Friday.
* On 03/02/24, a note entered under swing shift, informed staff Resident 2 needed a shower.
* On 03/03/24, a note entered under swing shift, "[resident 2] never got [his/her] shower that [s/he] wanted".
* There was no documented evidence Resident 2's shower was provided.
On 03/06/24, these findings were reviewed with and acknowledged by Staff 1 (Executive Director).
Verbal Plan of Corrections:
Administrator will ensure resident's shower is provided by staff on duty.
Based on interview and record review, during a site visit on 03/05/24 and 03/06/24, it was determined the facility failed to provide and document delegation and teaching by a registered nurse for 1 of 2 residents (#s 11) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:
According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.
In an interview on 03/05/24 at approximately 10:20am, Staff 4 (RCC) identified Resident 11 and Resident 12 to be administered insulin injections by non-licensed staff.
On 03/06/24, a review of Resident 11's MAR, dated 01/01/24 through 01/31/24, indicated the resident received Lantus (insulin to treat diabetes) once daily. The insulin had been given by Staff 15 (former MT), Staff 17 (former MT), and Staff 18 (former MT) on multiple occasions and Staff 16 (Life Enrichment Director) had given insulin once.
On 03/06/24 at 3:45pm, CS reviewed delegation binder with no avail for Staff 15, 16, 17 and 18.
On 03/06/24 at 4:30pm, Staff 1 (ED) searched Staff 19 (RN) office for delegation records. Staff 16, 17 and 18 had no documented evidence delegation and training were completed by the facility RN.
A review of Staff 15's delegation record indicated delegation was rescinded due to "quit 12/30/23".
A review of Resident 11's MAR, dated 01/01/24 through 01/31/24, indicated Staff 15 administered insulin on 01/07, 01/08, and 01/09 after delegation was rescinded.
On 03/06/24, these findings were reviewed and acknowledged by Staff 1 (Executive Director) who in response to Staff 16's one-time administration stated "[Staff 16] said someone must've been logged in under [him/her]".
Verbal Plan of Corrections:
The Administrator, Wellness Service Director, and RN will audit and verify current staff delegations.
Based on interview and record review, conducted during a site visit on 03/05/24 and 03/06/24, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 3 sampled residents (#12) whose MAR/TARs were reviewed. Findings include, but are not limited to:
A review of Resident 12's MAR, dated 01/01/24 through 02/29/24, indicated the following:
* "Humalog Kwikpen 100u/M; 5x3ml. Inject 3 units subcutaneously three times daily before meals; Hold if pre-meal CBG less than 120."
* On 01/01/24 at 7:30am, Staff 22 (former MT) noted CBG was 86 and administered the insulin.
* On 01/02/24 at 7:30am, Staff 9 (MT) noted CBG was 86 and administered the insulin.
* On 01/07/24 and 01/08/24, Staff 23 (former MT) noted CBG was 99 and 78, respectively, and noted an injection site where treatment was administered. The MAR asked, "did you hold dose", Staff 23 noted 'yes'.
* On 01/10/24, Staff 9 noted CBG was 74 and noted an injection site where treatment was administered. The MAR asked, "did you hold dose", Staff 9 noted 'yes'.
* On 01/11/24, Staff 4 (RCC) noted CBG was 81 and noted an injection site where treatment was administered. The MAR asked, "did you hold dose", Staff 4 noted 'yes'.
* On 01/17/24, Staff 9 noted CBG was 90 and noted an injection site where treatment was administered. The MAR asked, "did you hold dose", Staff 9 noted 'yes'.
* On 01/21/24, Staff 23 noted CBG 103 and noted an injection site where treatment was administered. The MAR asked, "did you hold dose", Staff 23 noted 'yes'.
* "Humalog Kwikpen 100u/M; 5x3ml. Inject 3 units subcutaneously three times daily before meals; Hold if pre-meal CBG less than 120."
* On 02/02/24 at 4:30pm, Staff 18 (former MT) noted CBG was 120 results and withheld the medication.
* On 02/14/24 at 11:30am, Staff 20 (MT) noted CBG was 120 and administered the insulin.
In an interview on 03/06/24 at 4:30pm, Staff 3 (Wellness Services Director) stated if the physician parameters said to hold insulin if CBG is less than 120, then s/he expected to be administered if resident's CBG is 120 or above.
On 03/06/24, these findings were reviewed and acknowledged by Staff 1 (Executive Director).
Verbal Plan of Corrections:
The Administrator and Wellness Services Director will provide MT training.
Based on interview and record review, conducted during a site visit on 03/05/24 and 03/06/24, it was determined the faciltiy failed to keep an accurate medication administration record. Findings include, but not limited to:
A review of Resident 12's MAR, dated 01/01/24 through 02/29/24, indicated the following:
* On 01/13/24, seven medications scheduled for 8pm were blank and no indication if these medications were administered or not and why.
* On 01/02/24, 01/06/24 at 4:30pm, the scheduled 3 units of insulin were blank;
* On 01/16/24 at 07:30am the scheduled 3 units of insulin and 26 units of routine insulin were blank and no indication if these medications were administered or not and why.
* On 02/21/24, 02/23/24, and 02/25/24 at 4:30pm, an order for Humalog Kwikpen to inject 3 units three times daily for diabetes required CBGs to be taken and to hold dose if CBG is less than 120. There was no CBG reading notated and the 'Exceptions' indicated "task performed as scheduled."
On 03/06/24, these findings were reviewed and acknowledged by Staff 1 (Executive Director).
Verbal Plan of Correction:
The Administrator and Wellness Services Director will provide MT training.
Based on interview and record review, conducted during a site visit on 03/05/24 and 03/06/24, it was confirmed the facility failed to provide qualified direct care staff sufficient in numbers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:
In an interview on 03/04/24 at 1:30 pm, Witness 3 and Witness 4 stated during an unannounced visit in the morning of 03/01/24, the facility's Resident Care Coordinator was working as both - medication technician and a caregiver because of short staffing. When this was brought to the attention of the Administrator, s/he stated the LPN would be pulled in to cover.
A review of the facility's posted staffing plan, (undated), indicated the facility's current staffing plan was:
* Day Shift: 6 am to 2 pm:
* 2 Medication Techs
* 2 Caregivers
* Swing Shift: 2 pm to 10 pm:
* 2 Medication Techs
* 1 Caregiver
* Night Shift: 10 pm to 6 am:
* 1 Medication Tech
* 1 Caregiver
The facility's posted staffing plan on day and swing shifts did not exceed the ABST care time.
A review of the facility's ABST indicated 4 residents were not entered into the tool.
A review of staff schedule, dated 03/2024, timecards, dated 03/01/24 and 03/05/24, and agency invoices, dated 02/08/24 through 03/02/24, indicated on Friday, 03/01/24 and Tuesday, 03/05/24 day shift had a call off on day and swing shift and lacked a plan for coverage leaving the facility short-staffed by 1 caregiver.
In separate interviews on 03/05/24, Staff 4 (RCC), Staff 21 (MT) stated the facility needed 2 CGs and 2 MTs on day and swing shift.
In an interview on 03/05/24, Resident 2 stated s/he requires hands on assistance with showers and his/her shower schedule is on Friday and Tuesdays. S/he was not provided a shower on Friday.
In a follow up interview on 03/06/24 at 10:07 am, Resident 2 stated s/he did not get a shower yesterday.
In an interview via telephone on 03/08/24, Staff 3 (Wellness Service Director) stated s/he does not provide care in the role, but on 03/01/24, s/he was notified "mid-day around 11:00 am" that coverage was needed, and it was "all hands-on deck."
On 03/27/24 at 11:45 am via telephone, these findings were reviewed with and acknowledged by Staff 1.
Based on observation, interview and record review, conducted during a site visit on 03/05/24 and 03/06/24, it was determined the facility failed to implement and update an acuity-based staffing tool (ABST), and consistently staffing to meet the needs of all residents. Findings include, but are not limited to:
On 03/05/24, Compliance Specialist observed Resident 1 move into the facility, Resident 2 and Resident 3 were in the community, and Resident 4 had a sign on his/her door that stated: "out of facility".
At the entrance conference interview on 03/05/24, Staff 1 (Executive Director) stated s/he is responsible for updating the facility's ABST while Staff 3 (Wellness Services Director) is still training.
a. In an interview on 03/06/24, Staff 1 stated the facility used the state's ODHS ABST and the facility is home to 63 residents, and Resident 4 was out of the facility in rehab.
b. A review of the facility's ABST with Staff 1 indicated four residents- Resident 1, Resident 2, Resident 3, and Resident 4 were not entered into the tool.
A review of resident and facility records indicated:
*Resident 1 was admitted on 03/05/24.
*Resident 2 and Resident 3 were long-term residents actively residing in the facility.
*Resident 2 experienced a significant change of condition 12/13/23.
c. A review of staff schedule, dated 03/2024, timecards, dated 03/01/24 and 03/05/24, and agency invoices, dated 02/08/24 through 03/02/24, indicated on Friday, 03/01/24 and Tuesday, 03/05/24 day shift had a call off on day and swing shift and lacked plan for coverage leaving the facility short-staffed by 1 caregiver.
d. In an interview on 03/05/24 at 3:50 pm, Resident 2 stated s/he was not provided lunch on four occasions in the last 30 days and did not get a shower on his/her shower day on Friday, 03/01/24.
In an interview on 03/06/24 at 10:07 am, Resident 2 stated s/he did not get his/her shower on 03/05/24 that Staff 14 said s/he would provide.
A review of Resident 2's service plan, dated 12/28/23, and progress notes, dated 03/02/24 through 12/08/23, and the facility's resident shower schedule (undated) and 24-hour communication logs, dated 03/02/24 through 03/06/24, indicated the following:
* In the area of bathing, faciltiy staff would provide "a moderate degree of assistance.... assistance may include reminding/prompting... setting up shower.... assisting into tub/shower, washing back and/or hair, and cleaning up afterwards...." and "[same gender as resident] only to assist."
*A progress note entered on 03/02/24 at 6:25 pm, indicated Resident 2's daughter called to request resident got a shower on Sunday on 03/03/24.
* Resident 2 was scheduled for showers during swing shift on Tuesday and Friday.
* There was no documented evidence Resident 2's shower was provided on Friday.
It was determined the facility failed to implement and update an acuity-based staffing tool.
On 03/06/24, these findings were reviewed with and acknowledged by Staff 1.
Based on observation, interview, and record review, conducted during a site visit on 03/05/24 and 03/06/24, it was determined the facility failed to document they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised for 2 of 3 sampled staff (#s 8 and 14) whose training records were reviewed. Findings include, but are not limited to:
A review of facility records indicated Staff 8 (MT) was hired on 02/07/24 and Staff 14 (MT) 01/31/24.
On 03/05/24 and 03/06/24 during swing shift, the Compliance Specialist (CS) observed Staff 8 and Staff 14 administering medications independently and unsupervised.
On 03/06/24 at approximately 11:00am, CS requested training records for sampled staff. At 4:45pm, Staff 2 (BOM) confirmed only 1 of 3 training records were located. There were no available training records to be reviewed for Staff 8 and Staff 14.
In an interview on 03/05/24 at approximately 4:30pm and 03/06/24 at approximately 5:00 pm, Staff 8 stated training program included on-the-job shadowing on the first day. The second day little hands on, then the third day was a "walk through" which was more on-the-job shadow, and on the fourth day, s/he was shadowed. Staff 8 was independent with this task by the second week of employment. Staff 8 stated s/he was shadowed by Staff 4 and signed off on a training sheet.
The facility failed to document they have observed and evaluated the individual's ability to perform safe medication and treatment administration unsupervised.
On 03/06/24, these findings were reviewed and acknowledged by Staff 1 (Executive Director) who stated the training documents were out with Staff 14 or were held with Staff 4.
Verbal Plan of Corrections:
Within a week, the Administrator or Wellness Service Director will evaluate identified MT for competency and the Administrator or designee will follow up with their trainer to ensure training documentation is turned in.
Based on observation and interview, conuducted during a site visit on 03/05/24 and 03/06/24, it was determined the facility failed to maintain thresholds and floor juntures to prevent tripping hazard. Findings include but are not limited to:
During the site visit, the Compliance Specialist observed on the first and/or second floor the following:
* Carpet near med tech station where residents sign in and out from the facility and get vitals taken had a long tear and was a potential trip hazard.
* Carpet junctures on second floor in the hallway where activitites are held and leads to the dining room had two raised flaps of carpet that was a potential trip hazard.
* A bench in the hallway outside of unit 226 was soiled and stained blackish-brownish-and reddish marks.
* Staff 11 (Building Services Director) was shampooing the carpets.
On 03/06/24, at 5:20 pm, the Compliance Specialist toured the facility with Staff 1, was shown the first and second floors carpeting, and confirmed the need to repair.
On 03/05/24 and 03/06/24, these findings were reviewed with and acknowledged by Staff 1 (Executive Director).
Verbal Plan of Correction:
Staff 1 will have Staff 11 remove the stained bench and will flatten the carpet.
It was determined the facility failed to maintain thresholds and floor juntures to prevent tripping hazard.